Imagining Life with “Immunity Passports”: Managing Risk during a Pandemic

Imagining Life with “Immunity Passports”: Managing Risk during a Pandemic

Giulia De Togni, Nicola Boydell, Sarah Chan, Sonja Erikainen, Andrea Ford, Agomoni Ganguli-Mitra, David Lawrence, Catherine Montgomery, Martyn Pickersgill, Rebecca Richards, Nayha Sethi, Julia Swallow

For the next phase of the COVID-19 response, some governments – including those of Chile, Germany, Italy, the UK, and the USA – have asserted that the detection of antibodies to SARS-CoV-2 (the virus that causes COVID-19) could serve as the basis for an “immunity passport” or “risk-free certificate” (WHO 2020). Assuming that antibodies would protect against re-infection, these measures would, in theory, enable individuals to travel or return to work. However, the extent of this travel remains unclear, while such practices of surveillance also raise scientific, social, ethical, and legal concerns.

As of end of May 2020, in the UK, antibody tests are not yet widely available, though they are now being offered to NHS and social care staff, and to NHS hospital inpatients and care home residents based on their clinician’s advice (UK Government). Public Health England (2020) has evaluated tests by Roche and Abbott, which are reported by the manufacturers and government as being “100% accurate” (Burki 2020). However, many scientists  have raised doubts about this claim as laboratory tests are still unable to clearly distinguish between past infections caused by the known set of six human coronaviruses (WHO 2020).

In a scientific brief published in late April 2020, WHO wrote: “People infected by any one of these viruses may produce antibodies that cross-react with antibodies produced in response to infection with SARS-CoV-2”. Consequently, those who have antibodies for other coronaviruses may be wrongly categorised as immune to COVID-19. If the tests remain inaccurate, people with false positive results may unwittingly be “walking hazards” who could become infected and spread the virus (Patel 2020).

Furthermore, a regime of “immunity passports” may serve political ends by providing tools to monitor and shape behaviour of individuals and groups, and potentially depriving individuals of fundamental human rights. Under the ‘antibody politics’ of COVID-19, the development and adoption of any kind of immunity certification – as well as digital tracking technologies – will have important consequences for the individual liberty and rights of those considered immune, as well as those who will not have attained or be able to demonstrate immune status.

In the not-so-distant future, this process could translate into difficulty obtaining medical insurance in contexts without a robust public healthcare system, or into unemployability if inadequate data privacy allows employer discrimination – effectively creating a “second class” of “immuno-deprived” versus “immuno-priviledged” individuals (Kofler and Baylis 2020).

The COVID-19 pandemic is already mirroring existing social and health inequalities, and is exposing the pre-existent fragilities of underfunded health and social care systems. For instance, a recent study shows that Black and Asian people in the UK are respectively 71% and 62% more likely than white people to die from COVID-19 (Valdes 2020). Unresolved questions around the social and ethical implications of COVID-19 antibody testing and immunity certification need to be addressed before any widespread adoption – and equitable policies need to be designed and established to ensure that the answers translate into practice. The following three scenarios provide a glimpse of some of the complex issues associated with COVID-19 antibody testing and immunity certificates.

In the first scenario, imagine you are an NHS intensive care nurse at the front line of the COVID-19 outbreak response, exposed to high risk of infection, long working hours, psychological distress, and fatigue. Your employer offers you an antibody test but you receive a false positive – which means that you are thought to have had COVID-19 and to have antibodies to SARS-CoV-2, while in reality, you remain at risk of infection. However, based on the (false) positive result, your work shifts are increased, and you are given more COVID-19 focussed work – heightening your risks of contracting the virus, infecting others, and getting burnt out. The false positive puts you, your patients, your family members, and the individuals they each come in contact with, at risk.

In the second scenario, imagine you are an immigrant trying to join your family in the USA, where “immunity passports” have become mandatory for entry. You are stopped at the border and questioned about your official antibody status. However, you do not have the required documentation because your government does not provide it. You are then kept indefinitely in an immigration detention centre in the USA, where a high degree of human interaction occurs. Inadequate implementation of infection prevention strategies is currently affecting the spread of COVID-19 and other diseases in the incarcerated community (Meyer et al. 2020). This means that – aside from the social and psychological burden of being detained – you are now at a higher risk of contracting COVID-19 and are unlikely to receive adequate care should you become seriously ill.

In the final scenario, imagine you are an EU citizen living in the UK. Recently “risk free certificates” have become mandatory for returning to work. In principle, this should be fine: you have a certificate from your home country, demonstrating that you have recovered from COVID-19. However, you discover that the UK is providing certification on the basis of a different antibody test to your home country.  Since yours has not been approved in the UK, it is not recognised – and as an EU citizen post-Brexit, you are far down the priority list for people to obtain testing and a certificate, and the expense is considerable. You remain unemployed and your residence/visa status is now under threat.

These three scenarios aim to show how individuals deemed at-risk, or those who face compounded social disadvantage, could likely face greater challenges to their physical and mental health security, and well-being if “immunity passports” or “risk-free certificates” become mandatory. Other individuals may also be refused these certificates because they are deemed at ‘higher risk’. These include people with chronic illness; those who have had an organ transplant; people who have received chemotherapy or antibody treatment for cancer; those who have blood or bone marrow cancer such as leukaemia; those who have a severe lung- or heart condition; and pregnant women (NHS 2020).

In fact, the current pandemic importantly intersects with other pre-existing health conditions. Moreover, “risk-free certificates” rely on the assumption of a clear disease trajectory (symptoms, recovery, immunity) and effective public health infrastructures, but efface ongoing disruptions to health over time – neglecting the emergence of chronic illness as a consequence of COVID-19. Further work is needed to define how COVID-19 relates to other illness, and indeed to redefine what “health” means and what “fit to work” or “infectious/immune” mean in this context.

Among policy speculations about testing and immunity passports or certificates, the varying effects of these on different members of society – and, indeed, societies – has not been sufficiently interrogated or addressed. Inevitably, differences will be marked along existing lines of inequality, mirroring the biomedical and psycho-social impacts of COVID-19.

These “technologies of social closeness”, we predict, would rely on digital infrastructures and practices of identity confirmation that might be taken for granted by politicians espousing them – while being undesirable or possibly inaccessible to many who might want or be required to obtain them. In terms of privacy, for instance, it remains unclear how the results of antibody testing will be collected, how identifiable these data will be, for what purposes they will be used, with whom they will be shared and under which circumstances.

Public trust, solidarity, and addressing social injustices are key factors to the success of testing, contact tracing, quarantine of contacts, and isolation of cases (Phelan 2020). However, immunity passports or certificates may intersect with pre-existing state-surveillance practices, particularly of marginalised groups (Kofler and Baylis 2020). As such, they may bring into being new kinds of publics, and re-shape or limit spaces of public participation in health and social life. This may lead to public distrust, division, and more injustices.

Furthermore, rewarding immunity with freedom of movement, including the ability to return to school and work, is a particular style of biopolitics that may increase instead of mitigate risk. Some individuals may intentionally try to contract COVID-19 in order to obtain “risk-free certificates” to enable them to re-enter the workforce (Bauer 2020). For instance, “exposure parties” – which are already practised as an alternative to chickenpox vaccination – could find favour in the current pandemic, with potentially significant individual and public health consequences (Kates 2020).

The imposition of antibody testing and immunity passports plays on – and exacerbates – structural vulnerabilities, and it does not protect the rights and interests of those who cannot demonstrate immunity. Moreover, how much immunity infection confers, and for how long, is still unknown (Studdert 2020). This style of biopolitics promotes thinking about individual prerogatives instead of social solidarity, also raising questions about what kinds of health for which publics we want to cultivate and protect.

Ultimately, the notion of using medical testing for a disease as a means of apportioning vital freedoms and resources raises substantial social and ethical concerns. COVID-19 antibody testing and immunity passports are likely to exacerbate existing inequalities if they: (a) are not backed-up by reliable data and adequate social policy that address the concerns and needs of those facing severe social and health-based disadvantage; and (b) fail to reflect the outcomes of thoughtful engagements with communities who will both benefit from and potentially be penalised by these innovations. Until these conditions are met, we cannot recommend the introduction of so-called “immunity passports”.

 

Giulia De Togni, Nicola Boydell, Sarah Chan, Sonja Erikainen, Andrea Ford, Agomoni Ganguli-Mitra, David Lawrence, Catherine Montgomery, Martyn Pickersgill, Rebecca Richards, Nayha Sethi, Julia Swallow. All authors are based at the Centre for Biomedicine, Self and Society at The University of Edinburgh, Scotland, United Kingdom

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