Exploring the evidence, ethics, and pitfalls around vaccine certificates

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At some point in the not too distant future, vaccine certificates are expected to be a requirement for international travel.

But what should they look like and what issues must be taken into consideration?

Dalhousie University Research Professor and bioethicist Françoise Baylis says policies around COVID-19 vaccine certificates must be evidence-informed and ethically sound, and we all need to be aware of the potential pitfalls of such a document.

“Everybody who gets one of these documents might experience increased freedom,” Baylis said in an interview.

“But everybody who cannot get one of these documents is going to experience a decrease in freedom relative to what others in the population can do. We need to always be thinking about both parties — those who benefit and those who will be disadvantaged.”

Canadians embracing idea of vaccination passports

Last week an Angus Reid poll examining Canadians’ views about so-called vaccine passports found 76% supported mandatory vaccination proof for travel to the U.S., and 79% agreed it should be required for international travel beyond the borders of the U.S.

In addition, 55% of respondents said proof of vaccination documents should be mandatory in public places (restaurants, malls, churches, theatres), with 41% stating they shouldn’t be mandatory.

When asked if proof of vaccination should be required at their place of work, 55% said yes, with only 37% indicating disagreement.

“I think a lot of people are in favour when they don’t have all the information,” Baylis said.

“If they are just presented with ‘Hey, you know, you’ve been a good person, you’re out there getting your vaccine, don’t you think that once you’re fully vaccinated, you should be free to get back to a regular life?’ Most people would say ‘Well, yeah.’”

While the ultimate goal is population immunity — ensuring enough of us are vaccinated to protect those who can’t be or have chosen not to be — Baylis said we need to start thinking about how we move forward.

That includes how we approach issues like vaccine certificates, and as it turns out there’s  a great deal to consider.

One more way of policing law-abiding citizens?

Baylis started thinking and writing about this issue during the earliest days of the pandemic. A thread woven through her explorations are around how vaccine certificates could increase issues of inequity and further disadvantage communities already facing challenges.

She said once government decides on a form of certification, they need to determine where it will be used, for what purpose, and who can — and cannot — demand to see it.

“I’ve spoken specifically about the problem we have here in Nova Scotia with carding, and I say that’s not old news, that’s contemporary,” Baylis said. “We have data that confirms this is a problem.”

“Now, what happens when law enforcement can just walk around and say to everybody ‘OK, where is your vaccine certificate? I want to see it.’ Does it just become one more way of policing law-abiding citizens?”

Certificates, she said, need to support public health objectives but can’t further entrench inequality or exacerbate mistrust. Documentation about vaccinations must be provided free of charge, and while a digital certificate might work for a large percentage of the population, Baylis said such certificates must also be made available in a more accessible format.

“You cannot assume that your ticket to freedom is dependent upon you having enough money to have a cell phone and a cell phone plan,” she said.

The world going back to the way things were before should also never be the goal, Baylis said, because “things were pretty crappy” for many people pre-pandemic.

“The goal should be what can we learn in the moment and how can we use it to build a better world,” she said. “When you think about these vaccine certificates, understand them as a platform and then think about how you can make sure that whatever you build does not exacerbate already existing inequalities.”

Equitable access for young people

The importance of equitable access was also highlighted in an Impact Ethics piece published last week. Michael Crawford, a professor of biomedical sciences at the University of Windsor, believes rushed vaccine certificates harm young people and herd immunity. He argued that we shouldn’t implement such certificates until youth and young adults are all vaccinated.

“Otherwise we risk fostering a climate of mistrust, and breeding the variants and outbreaks we all need to avoid,” Crawford wrote.

“We need to show the same solidarity with our young that they have shown to us when we, as elders, were the most vulnerable. Failure in this regard will mark a breach of faith, but also risk sacrificing herd immunity and encouraging a fourth wave in the name of economic expediency.”

Why vaccine ‘certificate’ is better than ‘passport’

Baylis believes the language we use is important, which is why she rejects the term “vaccine passport” in favour of “vaccine certificate.”

“You do not want to entrench the concept that I need a passport to leave my house. I want to go to church. Oh, I need my passport. I want to go into a bar. Oh, I need my passport,” she said.

“That’s just kind of crazy, and it really undermines the concept of what a passport is about. A passport is typically used for crossing borders, and we need to keep that language for the purpose of crossing borders.”

On Sunday, the British daily newspaper The Telegraph broke the news that their government was set to scrap its plans to use vaccine passports as a legal requirement for attending large events.

The article noted that while proof of vaccination has become accepted for international travel, “their use within the UK is much more controversial, with critics warning that making people show proof of their medical status for social events raises serious ethical questions.”

Sunset clauses

While the current science provides us with information on safety and efficacy of vaccines, Baylis said it doesn’t yet provide us with all the evidence we’d like around transmissibility of the virus, for example.

Last month, she and colleague Natalie Kofler co-authored a paper, What Canada needs to consider in its plans for vaccination certificates. It summarizes the current Canadian scientific considerations around such certification and highlights the fact that the World Health Organization currently advises against vaccination certificates “due to scientific uncertainty about vaccine impacts on viral transmission and inequitable vaccine distribution.”

Baylis and Kofler also call for a “sunset clause” with timelines and expiration conditions should vaccine certificates be implemented to ensure the routine screening of travellers “on the basis of biology” not become part of the new normal.

If you’re going to be increasing or decreasing people’s liberty of movement, Baylis said you must have good science to back it up. In addition to the science, she said we need to recognize who does — and does not — have access to COVID-19 vaccines.

“The issue of inequity and privilege comes into play and now it comes into play not only within nations, but across nations in terms of access. Also, a number of concerns get raised about the fact that some people will never be able to be vaccinated,” Baylis said.

“What are you saying to those people and to those who may choose not to be vaccinated, which is a different group of people. Are you just going to permanently disenfranchise them and say they can’t travel anymore? You need to really think that through.”

Should vaccines be the only way forward?

Baylis points to more recent iterations of these certificates, noting how the European Union’s “digital COVID certificate” demonstrates how the language has shifted away from passports. She said vaccination in and of itself can’t be the only standard that’s used.

On Tuesday, the European Commission announced that seven EU countries — Bulgaria, Czechia, Denmark, Germany, Greece, Croatia, and Poland — had decided to connect to their  digital COVID certificate gateway and had started issuing their first certificates. More EU countries are expected to launch in the coming days and weeks.

The digital COVID travel passes are free, provided in digital and/or paper format, and are deemed safe and secure. They’ll allow people to move within the EU’s 27 member states in time for the summer tourist season.

To obtain such a certificate, people must fall into one of three categories: they are fully vaccinated; they can prove they had COVID-19 and are fully recovered; or they agree to continue with current public health protocols, which means testing before travel, quarantine, and testing after travel.

“You wouldn’t have to be vaccinated, but your freedom would be constrained in pursuit of a public health goal or you would have to be able to show that you have had and recovered from COVID-19,” Baylis explained.

Concerns about ‘technological creep’

Baylis said it’s important for policymakers to keep in mind that by creating a digital certificate, they’re also building a platform that can have negative consequences in addition to benefits.

Will the certificate only contain your COVID-19 vaccine status? Or does it grow to include all your vaccinations, and then eventually your entire digital health record? If a provider wants access to your electronic record, what could that mean for obtaining health or life insurance?

“You can see the technological creep that I could be worried about,” Baylis said. “What I’m saying is if you’re going to think about doing this, you have to think about how you could anticipate it being used and what precautions you are going to put in place around that.”

Obligation to the countries where you travel

When it comes to travel and tourism, Baylis said we need to consider the infrastructure required in the countries we intend to visit, as they must be able to receive and act on the documentation.

“Do you imagine that every low and middle income country in the world is going to be able, on a dime, to turn around and have all this technology to scan and read whatever digital documentation you have,” she asked.

“And do they then have the resources to police this?”

Last month, the United Nations World Committee on Tourism Ethics issued its recommendations on COVID-19 certificates for international travel. Baylis was one of the experts consulted during the creation of the document.

“I think that they got it pretty close to right in terms of the kinds of concerns that they’ve articulated,” she said. “They’re really emphasizing that you have an obligation to not only worry about the person who is travelling, but the people in the country they’re travelling to.”

That means that while you may be fully vaccinated and likely protected from the virus, what if the population of the country you’re visiting only has a 1% vaccination rate? What would happen if you were in a potential 5% of people who can spread the virus and you end up bringing it into a community you’re visiting?

“How would you feel if you went to the birthday party and now everybody who was there is ill and three people have died?” Baylis asked.

What about vaccines unapproved in Canada?

Baylis also suggests we need to think about how we’ll accept — or not accept — vaccines from around the world not approved for use in Canada. How do we deal with visitors from countries that have used different vaccines? How do we make allowances for countries that have no vaccines?

There will be costs associated with infrastructure required to investigate the efficacy of vaccines from other jurisdictions. Baylis wonders what happens if a country and/or its vaccine manufacturer refuse to submit information to Health Canada.

“Do we then say, well, OK, we don’t have the science for Sputnik V (Russian vaccine), so anybody with that vaccine just doesn’t cut it. They can’t come in,” she said.

“These are the things we really have to think about. It’s all of the logistical challenges. Quite frankly, it is going to be easier to recognize vaccines that we’ve already approved, but you surely can’t have that as a limit for the future.”

‘History will not judge us kindly’

While many are enthusiastic about the idea of vaccine certificates “in the abstract,” Baylis said there’s often a shift after they’re given a detailed explanation of the concerns.

Baylis said that like the pandemic, vaccines are about an “ethic of care for others” because they’re ultimately about protecting the community as much as yourself.

She echoes Nova Scotia’s chief medical officer of health, Dr. Robert Strang, who raised the ire of some cottage owners on May 19 by referring to them as “extremely privileged” for having two homes and urging them to pick one home and stay there.

“I know that many people did not appreciate that comment,” she said. “I’m on the side of those who did very much appreciate that comment. I think that we need to recognize our privilege in the world.”

“My colleague Natalie (Kofler) and I have talked about this in terms of immuno-privilege. One of the things that is happening is people who already have privilege in terms of where they live, in terms of the resources they have access to, are now wanting to claim another kind of privilege, which is this immuno-privilege.”

Baylis said she considers it an obligation to try and uplift others so they can enjoy some of the same privileges she’s been fortunate enough to have. She believes this notion has been a challenge for many throughout the pandemic, and the history books won’t paint a pretty picture:

The World Health Organization (WHO) and Tedros (WHO director general Tedros Adhanom Ghebreyesus) have said repeatedly this pandemic will not end for everyone until it ends for everyone, and until we address this as a global problem we are going to continue to have limits on our freedom. Honestly, the way to get the most freedom is to get everybody vaccinated and we’re not doing that. We are not attending to the biggest problem.

I think that one of the systemic mistakes we have made and continue to make is to think that this is about us … as opposed to the rest of the world … We already have so many benefits, we are in a safe place compared to so many people in the world, and we need to find ways to enjoy those benefits without only thinking about ourselves. Really, that is going to be the story of this pandemic, and I do believe history will not judge us kindly.

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