Why vaccine passports won't slow COVID spread, will hurt the poor and threaten medical ethics

Prescient, from October 2021:

Opinion: Why vaccine passports won't slow COVID spread, will hurt the poor and threaten medical ethics

 "1. What is the intent and what are the end points? Vaccine certificates impose a significant burden on the population. There will be ongoing costs to taxpayers to maintain this system, and businesses will bear costs for implementation and oversight, and may be subjected to fines. The additional uptake in vaccination rates in those who are either unvaccinated or without natural immunity from previous infection is unclear. Moreover, it is unclear whether vaccine certificates will impact those at greatest risk of severe disease either directly with increased rates of vaccination or indirectly with reduced rates of hospitalization and death, especially in hard-to-reach groups. In a rush to implement this system, governments have been unclear about how they will measure efficacy, which implies there may not be a clear plan on when to scale back; perceivably, this program could be in effect for years to come. With the precedent for vaccine certificates established, there may be a desire to include other seasonal viruses, excluding increasingly larger segments of society from “non-essential” services.

2. Can we stop transmission with vaccine certificates? Probably not. The latest data suggest that vaccination reduces transmission by around 50 per cent at six months with evidence of further waning thereafter. Vaccines may help to slow spread of the virus, but they will not achieve the kind of herd immunity we see with such diseases as measles. Vaccine certificates may offer a false sense of reassurance to those who are vaccinated, if the belief is that they cannot contract or transmit the virus. The data is clear that vaccines offer a substantial reduction in risk of serious illness and death. If the goal of the certificate program is to provide further protection to those already vaccinated, this both underestimates the substantial protection already afforded and overestimates the efficacy of the vaccine in reducing transmission. Vaccine certificates for “non-essential” services will not touch industries hit hardest in previous waves, such as warehouses and factories. Implementation of targeted approaches in at-risk workplaces makes more sense, with the deployment of mobile vaccination units, regular point of care testing and protected pay for those with symptoms or high-risk exposures.

3. What are the logistical considerations of such a program? Those who are fully vaccinated may be amongst those denied access if they do not have a printer or mobile device, or if they have forgotten their documentation at home. This will especially impact the poor, those who are homeless, those with developmental delays or those who suffer from cognitive impairment. Newcomers will be subject to another set of vaccines if those approved in their home country are not recognized here. Businesses will be asked to deny services, sometimes to long-standing, loyal customers, at the expense of lost income desperately needed after months of forced closures. In addition, we can expect the workloads of numerous providers (ie. doctors, religious leaders) to grow exponentially with the additional tasks of proving vaccination status or providing exemptions. This demand will almost certainly strain relationships at a time when rapport could facilitate positive decision-making around vaccination.

4. What are the unintended consequences? Let’s take the example of fitness gyms, which have been deemed “non-essential.” One of the most important risk factors for severe COVID-19 illness is obesity. Many people rely on gyms, especially during the winter months, to access physical activity and maintain their ideal body weight. Those who live in apartment dwellings may not have access to green spaces for exercise. Thus, by barring access to gyms, we are restricting physical activity, which in turn contributes to increasing rates of obesity and greater risk for severe disease.   Ironically, by excluding the unvaccinated from common social institutions, we run the risk of congregation of unvaccinated individuals outside of these institutions. When this does occur, it is more likely to be without mitigation measures. COVID-19 is spread through social networks, meaning that this action could increase the number of infections circulating amongst unvaccinated people, increasing adverse outcomes.

5. Why are people vaccine-hesitant? While it is easy to dismiss the unvaccinated as conspiracy theorists and selfish, this is overly simplistic and frankly inaccurate. The unvaccinated are disproportionately of lower socio-economic status, ethnic minorities and children. Many minority groups have legitimate reasons to distrust the medical establishment, based on a long and sordid history of racism and classism. Some are unable to get vaccinated because they cannot afford time off work for vaccination and post-vaccine side effects. It is imperative that we understand the unintended potential health equity impacts of vaccine certificates on specific population groups, and that we target our efforts to vaccinate these populations in a way that is respectful, accessible and meaningful. Perhaps the greatest oversight with vaccine certificates is the lack of recognition of natural immunity. Those who have been previously infected may not wish to receive vaccination. This conviction is supported by recent data that natural immunity is as good or better than vaccine-induced immunity. If this is true, why are we excluding those with durable protection from society? Moreover, a lack of acknowledgement of protection by way of natural immunity may serve to reinforce the optics of pharmaceutical involvement in policy-making.

6. Are vaccine certificates ethical? One of the most sacred principles in medical ethics is autonomy, meaning that an individual has the right to decide what happens to their body. Those with underlying health conditions may genuinely fear vaccines could worsen their overall health; a belief which requires empathy and education. Even the most well-informed individual cannot provide informed consent if their “choice” is coerced. Vaccine certificates render the individual in an impossible place of having to choose vaccination or loss of employment and exclusion from society. This impossible “choice” forces the hand of those in this predicament and ultimately results in consent under duress. While population-based data are reassuring in terms of overall vaccine safety, side effects do occur. How will we respond when vaccine-hesitant individuals experience a serious adverse event, claiming that they did not “choose” to have vaccination in the first place? Loss of trust in the medical establishment can lead to poor health outcomes, as patients may avoid care and be less receptive to medical management. Given that we have exceeded numerous vaccine targets and offered protection to those at greatest risk, we should make every effort at this time to maintain patient autonomy and guide with openness rather than exclusion.

Public health interventions need to take into account not only the immediate threat before us, but also the downstream negative effects that may occur as a result of our actions. The introduction of vaccine certificates threatens individual autonomy and societal norms, and runs the risk of further isolating marginalized groups without clear metrics to assess efficacy. The sacrifices that have been made throughout this pandemic are astonishing and we have achieved great success with excellent vaccine uptake overall. After a long and lonely battle, we need to remember, “we’re all in this together”; now, more than ever, we need to unite as a society."