S1E33: The Privilege of Immunity / Kathryn Olivarius, Juanita Mora, Esha Bhandari

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“An immunity passport system would create a two-tier system because it would divide all of us into those who are immune to COVID-19 and those who are not. And the people who are immune will get all of the benefits and privileges that come with that while everybody else who’s not immune will be in a second class status.” – Esha Bhandari

How do we balance the reopening of the economy with public health and safety? Some have proposed an “immune passport” system, where those with proven COVID immunity could be cleared to resume normal work and life. This idea is not a new one — it has been tried once before during the 19th-century Yellow Fever epidemic. In today’s episode, we examine the insidious use of “immune privilege” during the Yellow Fever epidemic, its historical impacts, and its parallels to today. Our host, Dr. Celine Gounder, speaks with Dr. Juanita Mora, an allergist and immunologist practicing in Chicago, Dr. Kathryn Olivarius, professor of history at Stanford University, and Esha Bhandari senior staff attorney with the ACLU Speech, Privacy, and Technology Project.

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Celine Gounder: I’m Dr. Celine Gounder, and this is “Epidemic.” Today is Tuesday, July 7th.

Dr. Juanita Mora is a first-generation Mexican American living in Chicago.

Juanita Mora: My dad was a butcher. My mom, a stay-at-home mom. My grandparents participated in the Bracero movement, which means they worked the lands here in the United States, and it led me to work really hard and be very involved with the Latino community.

Celine Gounder: Health officials in Chicago reported the city’s first COVID case on January 30th. Over the following weeks, Dr. Juanita Mora saw it take its toll on the Latinx community in Chicago. Juanita runs a private allergy and immunology practice, and so she decided to open it up to the community for COVID testing.

Juanita Mora: I wound up getting a lot of patients who for example had outbreaks at tortilla factories, at grocery shops, at meatpacking companies as well too where seven or eight of their coworkers were sick.

Celine Gounder: Her services were in high demand. But she saw a lot of anxiety in her patients. Especially those who were undocumented.

Juanita Mora: And, what wound up happened was, some were threatened and said, we’re not planning to do social distancing. We’re not planning to institute any actions, safety measures. Here’s a job if you want. It said, if you don’t then feel free to leave this job.

Celine Gounder: Walking away from a job wasn’t an option for most of her patients. But there wasn’t much they could do to demand safer working conditions of their employers.

Juanita Mora: These workers don’t have actual legal status. So they know that they have nowhere to complain to, and they fear deportation. They fear losing a paycheck as well, too.

Celine Gounder: And then, Juanita noticed something new. Employers started to require some of the workers Juanita was caring for to prove they didn’t have COVID before they could come back to work.

Juanita Mora: They had already done the nasal swab and had either come back positive or negative. And now they were actually wanting to go back to work, and they wanted guidelines as far as how to safely get back to work.

Celine Gounder: This is something we’ve seen around the world… since the beginning of the pandemic. Some people keep coming  up positive for COVID on the PCR tests long after they’ve recovered. But to get back to work, they’ve got to show evidence of recovery…

Juanita Mora: That’s one of the things that I started encountering is people who wanted me to write employers and say, well, they already had it and they can’t get it again.

Celine Gounder: And that’s where antibody testing comes in. It’s important to understand that these tests don’t prove that someone is immune to reinfection… but antibody tests are evidence that someone has recovered and no longer poses an infectious risk to others. But it’s not a stretch to imagine how such antibody tests could be used by employers in other ways…

Could a special type of COVID passport pave the way for some people to return to work or travel?

Some officials have floated the idea of immunity passports.

An immunity passport might be the answer here. It’s an idea, other countries like the U.K. and Chile are looking at… 

Celine Gounder: In theory, someone with COVID antibodies could get an immunity passport they’d present for travel, work, or to attend large gatherings, for example. This week on “Epidemic,” we’re discussing all that could go wrong if officials were to move forward with an immunity passport system. And to understand the potential consequences, we’re going back to the antebellum South, to 19th century New Orleans.

As the capital of the slave trade, New Orleans was thriving.

Kathryn Olivarius: But it was also the nation’s deadliest city.

Celine Gounder: This is Kathryn Olivarius. Kathryn’s an assistant professor of history at Stanford University. Back in April, she wrote an op-ed in The New York Times titled, The Dangerous History of Immunoprivilege. In the first half of the 19th century, Yellow Fever ravaged New Orleans.

Kathryn Olivarius: Between 1803 and the Civil War New Orleans experienced 22 full blown summertime epidemics of Yellow Fever.

Celine Gounder: Yellow Fever is vicious. It’s a virus spread by mosquitoes. Severe cases cause liver failure and jaundice, literally turning the whites of your eyes yellow. Fever, chills, and nausea are other symptoms—but one really sets it apart:

Kathryn Olivarius: Black vomit. At the end of a person’s illness with Yellow Fever, so the most famous symptom was they would regurgitate this coagulated blood that looked a lot like coffee grounds.

Celine Gounder: The virus arrived in the United States in 1793, when a group of refugees fled an outbreak in the Carribean and landed in Philadelphia. An estimated ten percent of Philadelphia’s population died in that first outbreak. Soon the disease spread to other coastal cities. But no city would suffer as much as New Orleans.

Kathryn Olivarius: In 1804 for example, the first year that America had taken control over New Orleans and Louisiana, a very, very terrible epidemic swept through town, killing thousands of people.

Celine Gounder: New Orleans was an attractive destination for people looking to strike out on their own. Immigrants arrived in droves—and this big influx of new people dramatically increased the spread of the disease.

Kathryn Olivarius: These people had no immunity or previous exposure to Yellow Fever in the past. We see these death tolls reaching higher and higher proportions. In 1853 for example, 12,000 people died over the course of three months, and this is one of the worst natural disasters in American history.

Celine Gounder: This was a really deadly century in U.S. history. Cities across the young nation were battling myriad epidemics of infectious diseases. There were lots of ways cities tried to curb the spread of disease back then.

Kathryn Olivarius: When we think about quarantines, people think about a barrier almost stopping all ships coming in. They’re actually quite complex. Often there’s this quarantine ground. There can be ships out in the Harbor or in port, or on the river, where infected people can be held for a period of time.

Celine Gounder: While we know now that Yellow Fever is spread by mosquitoes, the disease remained a mystery for decades. Scientists and doctors had no idea how it spread or why it was so deadly to some… while others escaped with mild symptoms. There was one thing, however, that they did know.

Kathryn Olivarius: For example, in New York Harbor, they will have, you know, a smallpox quarantine they’ll have a ship quarantine. Often there’s this quarantine ground that can be shipped out in the Harbor or in Porter on the river where infected people can be held for a period of time.

Celine Gounder: Other cities shut down their ports and businesses, kind of like we’re doing with coronavirus today. But New Orleans was reluctant to take these steps.

Kathryn Olivarius: These are expensive, and why spend money on delaying the inevitable?

Celine Gounder: And so, politicians there took a different—more fatalistic—approach.

Kathryn Olivarius: The attitude became essentially that we can’t stop Yellow Fever, but we have to figure out a way to make society work in spite of mass death.

Celine Gounder: Kathryn calls this idea “immuno-capital.”

Kathryn Olivarius: It’s sort of a super power. Immuno-capital is the sort of ability to leverage your immunity, convince others that you are immune and leverage your immunity for greater social, economic, and political power.

Celine Gounder: Back then, developing immunity was known as being “acclimated.” And it was difficult to prove, because at the time, no one knew if surviving Yellow Fever actually made them immune.

Kathryn Olivarius: The long and short of it in some sense is that you didn’t actually totally know. You had a pretty good sense, you thought probably you were, but there’s always a sliver of a doubt in your mind.

Celine Gounder: And sometimes, people didn’t even know if they’d had Yellow Fever. It could have been malaria… cholera… typhus… typhoid… or tuberculosis. They all have overlapping symptoms, and they were all common in the 19th century.

Kathryn Olivarius: A part of the sort of social code of New Orleans and a part of, you know, being able to leverage immuno-capital was in your ability to convince others that you were immune.

Celine Gounder: Maybe you’d become immune in the first outbreak, back in the early 1800s. Maybe you’d become immune last week. Either way, convincing those around you took on a life of its own.

Kathryn Olivarius: People would be boasting loudly about how they were acclimated back in 1803, or back in 1817. And they have these, they sort of incorporate these stories like war stories almost. And they will describe their symptoms in great detail.

Celine Gounder: For young white men, it was their only hope of employment. Let’s pretend you’re writing up a resume for a job at this time in New Orleans. “Survived Yellow Fever” would be right at the top. Your most valuable qualification didn’t have anything to do with your experience on the job. It was your immunity. Without that? Good luck.

Kathryn Olivarius: It’s fundamentally about placing value on people who are acclimated or immune because from boss’s perspectives, and you know, in this incredibly lethal and sort of mercenary city, it wasted time and energy to train somebody for a job, you know, in May only to watch them sicken and die by the autumn.

Celine Gounder: It was a cruel calculus.

Kathryn Olivarius: The boss would ask you, so, describe your symptoms, go through and convince me that you know what you’re talking about. You know, how many years have you been in New Orleans uninterrupted? How many summers have passed? Are you parents from here? Can you produce a doctor’s certificate onto this effect? If you’re unacclimated, you couldn’t get a job.

Celine Gounder: It impacted everything else, too. Housing…

Kathryn Olivarius: You couldn’t live in certain places.

Celine Gounder: Marriage…

Kathryn Olivarius: Fathers would not let their daughters talk to unacclimated men less she fall in love with him and, you know, he dies and she’s left heartbroken.

Celine Gounder: Everything…

Kathryn Olivarius: You’re left in a sort of liminal insecure state financially. And, you know, it deeply impedes your ability to be sort of socially accepted in this place. If you are acclimated, however, though, if you’re rich, if you’re white this is a mark of permanence.

Celine Gounder:  For young white women, being acclimated raised their marriage prospects. For free people of color—and there were many in New Orleans at the time—being acclimated offered a greater shot at prosperity. For enslaved people, however, acclimation had little benefit. Immuno-capital instead created another way for white people to justify slavery. They came up with a theory…

Kathryn Olivarius: Doctors, laypeople, they all sort of forwarded this idea around the Atlantic world but especially in the south that all black people were naturally immune to Yellow Fever. It’s not true. There is zero epidemiological basis for this.

Celine Gounder: Just… an economic one.

Kathryn Olivarius: So, with this idea that all black people were naturally immune, you can justify racial slavery on an unprecedented scale. You can say that, you know, slavery is natural, even humanitarian, as people said back then, because it kept white people away from spaces and labor that would kill them.

Celine Gounder: White men didn’t even buy their own lies.

Kathryn Olivarius: So on the one hand you have this mythology that all black people are naturally immune to Yellow Fever, but in the slave market no slave holder would purchase a person without an express guarantee of acclimation.

Celine Gounder: When enslaved people were acclimated, they became significantly more valuable.

Kathryn Olivarius: Selling for between twenty-five and fifty percent more than unacclimated slaves.

Celine Gounder: Of course, the enslaved person never benefited from their own immuno-capital.

Kathryn Olivarius: So in some sense, black immunity became white capital in this society.

Celine Gounder: This focus on Yellow Fever immunity created a system where the mission was clear.

Kathryn Olivarius: It was considered your sort of duty first to get acclimated. For poor people, you end up being sort of forced into making choices, these terrible choices that maybe people should never have had to make in the first place where you have to actively seek sickness as this pathway to prosperity.

Celine Gounder: If public officials today were to move forward with any plans for immunity passports, the same dilemma could soon become our new reality.

Esha Bhandari: The only way to show that proof of immunity is to get COVID-19 and to hope that you won’t get COVID-19 so badly that you’re either hospitalized or even worse.

Celine Gounder: This is Esha Bhandari, senior staff attorney at the ACLU’s Speech, Privacy, and Technology Project. I asked Esha to put the history of Yellow Fever in New Orleans into the context of our current COVID pandemic.

Esha Bhandari: So an immunity passport or an immunity certificate system would be one where people have some sort of verified way of showing that they have immunity to COVID-19 and then presumably they would use this certificate or passport to work in certain areas for certain employers that are requiring this.

Celine Gounder: Back in the 19th century, there was no real way to verify someone’s immunity to Yellow Fever. But with today’s science and technology, Esha’s concerned about how far reaching a system like this could become.

Esha Bhandari: You can imagine a variety of either government or private sector driven app-based immunity passport, or certificate systems. To my knowledge, we haven’t seen anything like this before now.

Celine Gounder: It would also create a new class system…

Esha Bhandari: An immunity passport system would create a two tier system because it would divide all of us into those who are immune to COVID-19 and those who are not. And the people who are immune will get all of the benefits and privileges that come with that while everybody else who’s not immune will be in a second class status.

Celine Gounder: These pressures are already weighing on workers like those Juanita told us about at the top of the show.

Esha Bhandari: I think that any system that incentivizes people to get a highly contagious and very dangerous disease, that’s bad for public health.

Celine Gounder: A system like this would disproportionately affect people of color. The pandemic has pushed unemployment rates for African Americans and Latinx workers to some of the highest on record.

Esha Bhandari: We know that people are suffering economically. We know that there’s a lot of hardship out there. And if people are told that they will get better access to the jobs, perhaps higher wages if they have immunity we can see the inevitable consequences of that. Some people will really try to get COVID-19 as the only way out of you know, dire economic circumstances. And I think the last thing that public health officials want to do right now, given the state of the worldwide pandemic, but especially in the United States, is incentivize more people to get COVID-19.

Celine Gounder: Any system that incentivizes people to get infected with COVID puts lives at risk. But again, people of color in the United States would face an even more perilous decision. These communities have higher than average rates of underlying conditions like hypertension and diabetes, which are risk factors for severe COVID disease.

Esha Bhandari: A lot of these are disabilities. So people with these pre-existing conditions won’t really be able to take the risk of getting COVID-19. It would be playing Russian roulette with your life. So you’ll be putting people with disabilities in this very tough spot, where they’re unable to acquire immunity, even if they have the same incentives, because they’re economically vulnerable, they need to be able to go out and work. But for them, the risks of contracting COVID-19 are even greater.

Celine Gounder: But wait—don’t we already have a version of this? Lots of jobs require proof of vaccination or immunity. For example, restaurant workers have to get a Hepatitis A vaccine before they can work. There’s a whole slew of vaccinations I need to get as a doctor. Why would COVID be so different?

Esha Bhandari: An immunity passport system is fundamentally different from a system requiring proof of vaccination because in the latter system, people are not being asked to get ill with a disease in order to access critical life opportunities like employment, like access to healthcare, like ability to travel. In this circumstance, the only way to have immunity is to get COVID-19.

Celine Gounder: The concerns go well beyond the workplace…

Esha Bhandari: If you build a health surveillance infrastructure like this, it’s use will expand. And we’ve seen this with so many technologies in the past, with so many databases that were created for one purpose and then there is mission creep.

Celine Gounder: If you’ve read George Orwell’s classic novel, 1984, you’ll get a preview of what Esha’s describing.

Esha Bhandari: Depending on how an immunity passport system is created, it’s quite possible it could be centralized and hosted either by a handful of private companies or government agencies. And it’s very concerning to us because if that information about people’s health status is stored, particularly if it’s stored with additional information like their employer or their travel history or their housing information, that this information could be abused.

Celine Gounder: And these systems may even end up counterproductive as public health measures. Some groups may avoid seeking healthcare… fearful of how that information could be used against them.

Esha Bhandari: For example immigrant communities might be very reluctant to give their information over such a database because of the fears that it could be used against them. People might worry about consequences for them with their health insurance. Without airtight privacy protections, the system would be really vulnerable to abuse.

Celine Gounder: History’s repeating itself. In 19th century New Orleans, public officials took the same approach as many are again today: putting business and commercial prosperity over public health. Here’s Kathryn Olivarius again.

Kathryn Olivarius: They had made the economy work without having to promote the public’s health. So, you know, it’s not their job to essentially, you know, sort of provide the kind of public health infrastructure that would protect a person from the disease. In fact, it was their job to hasten that as much as possible. You know, our public health essentially is private acclamation.

Celine Gounder: And there’s a lesson in this. Here’s Esha again.

Esha Bhandari: I think that history should be our guide here. And I think that the studies of what happened during the past Yellow Fever outbreaks were very instructive. We should be very concerned if rather than investing either private or public funds to ensure a universal public health response that involves testing that’s accessible to all, that involves universal precautions that workplaces are required to take that protects all workers. If instead we moved towards a system of immunity passports, that will lead to the exploitation of workers, that will lead to vulnerable workers being most likely to need to contract COVID-19 just to be able to live at work. It is a system that will harm the most vulnerable among us. It will have disproportionate impacts on people with disabilities and workers of color, and it won’t necessarily do anything to keep all of us safe. So I think that we really should be suspicious of any quick fix or easy solution like this, instead of doing perhaps the harder work of ensuring universal worker protections that would apply to everybody.

Celine Gounder: “Epidemic” is brought to you by Just Human Productions. We’re funded in part by listeners like you. We’re powered and distributed by Simplecast.

Today’s episode was produced by Zach Dyer, Danielle Elliot, and me. Our music is by the Blue Dot Sessions. Our interns are Sonya Bharadwa, Annabel Chen, and Julie Levey.

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And check out our sister podcast “American Diagnosis.” You can find it wherever you listen to podcasts or at americandiagnosis.fm. On “American Diagnosis,” we cover some of the biggest public health challenges affecting the nation today. In Season 1, we covered youth and mental health; in season 2, the opioid overdose crisis; and in season 3, gun violence in America.

I’m Dr. Celine Gounder. Thanks for listening to “Epidemic.”

Dr. Juanita Mora Dr. Juanita Mora
Esha Bhandari Esha Bhandari
Kathryn Olivarius Kathryn Olivarius
Dr. Celine Gounder Dr. Celine Gounder