“When you’re building a system like a vaccine passport you’re potentially excluding millions of people because they don’t have this thing that once was optional, but has now become indispensable.” -Albert Fox Cahn
How do you let people who are fully vaccinated get back to normal life without creating super-spreader events for those who haven’t yet been vaccinated? Some are calling for vaccine certification programs that could hopefully re-open large parts of the economy safely while we still work on getting the vast majority vaccinated. In this episode, we’re going to hear about the ethics and logistics of vaccine certificates in the United States and around the world. We’ll hear the arguments for and against them, and how the burden of these programs falls unevenly around the world.
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JP Pollak: If you’re now trying to get on a flight and go somewhere outside of the U.S., you’re going to be asked to present a digital or paper versions of your immunization record or have negative test results.
Fatima Hassan: Proof of vaccination requirement is premature, and it’s premature because not everybody has the same opportunity and the same chance to be able to get vaccinated.
Céline Gounder: You’re listening to EPIDEMIC, the podcast about the science, public health, and social impacts of the coronavirus pandemic. I’m your host, Dr. Céline Gounder.
At the time of this recording, over fifty percent of American adults have been fully vaccinated. But that means there are still a lot of people in the United States who haven’t been vaccinated yet. This creates a difficult balancing act. How do you let people who are fully vaccinated get back to normal life without creating superspreader events for those who haven’t yet been vaccinated? This week the European Union implemented its digital green certificate. This is an electronic record of vaccination or a recent negative test result. The holder of a digital green certificate gets to travel freely throughout Europe. The United Kingdom has announced it would require similar proof for travelers to fly there. Israel was already using a similar system called the Green Pass. But the country’s health officials announced they were ending the program after just three months. The reason? More than 80% of the country has been vaccinated and new cases have plummeted. The system worked. Most people got vaccinated. And they don’t need the Green Pass anymore. And some are calling for a similar certification program here in the United States. The hope is that this could re-open large parts of the economy safely while we still work on getting the vast majority vaccinated.
Albert Fox Cahn: We’ve seen a lot of people in the private sector, pushing vaccine credentials, certainly commercial landlords who are eager to get people back to offices.
Céline Gounder: This is Albert Fox Cahn. He’s the Executive Director of the Surveillance Technology Oversight Project. Albert has been thinking about what these initiatives might entail.
Albert Fox Cahn: When these apps are being rolled out, uh, in our community, is being rolled out by employers that there’s a huge civil rights issue here and something that’s going to create a lot of problems that people haven’t really come to terms with yet.
Céline Gounder: Albert says he got vaccinated and hopes others will too. But he’s worried about how a requirement to show proof of vaccination to participate in daily life could create a more unequal society. He says seemingly simple requirements can prevent people from participating fully in society… like voter ID laws.
Albert Fox Cahn: Yeah, we often heard during the lead up to the 2020 election, that voter ID requirements are no big deal because how hard is it to ask someone to produce a driver’s license? And that’s such a privileged and myopic perspective because there are so many millions of Americans who don’t have a driver’s license, don’t have a government ID, who don’t have that proof of who they are. And when you’re building a system like a vaccine passport, if it becomes the ticket to daily life, you’re potentially excluding millions of people because they don’t have this thing that once was optional, but now becomes indispensable.
Céline Gounder: In this episode, we’re going to hear from Albert and others about the ethics and logistics of vaccine certificates in the United States and around the world. We’ll hear why some think they’re necessary…
Lawrence Gostin: The vaccine passports are probably the best way to get us back to some semblance of normalcy as soon as possible.
Céline Gounder: What some of the concerns are…
Albert Fox Cahn: I realized just how easy it would be to fake…
Céline Gounder: And how the burden of these requirements falls unfairly around the world…
Fatima Hassan: So it just seems that, instead of imposing travel ban restrictions. Why don’t you open up the, the knowledge and share the vaccine know-how and rather get to the point where everybody can travel?
Céline Gounder: Today on EPIDEMIC, Vaccine Certificates.
Before we return to Albert’s concerns about vaccine certificates, let’s hear why some are in favor of proof of vaccination.
Lawrence Gostin: Vaccine passports are probably the best way to get us back to some semblance of normalcy.
Céline Gounder: This is Lawrence Gostin. He’s a Professor of Global Health Law at Georgetown University and Director of the World Health Organization’s Center on Global Health Law.
Lawrence Gostin: We don’t want to always be masked. We don’t want to always have a six foot distance. And we don’t want to keep getting tested over and over and over again. And so vaccines are the best way to do that.
Céline Gounder: Lawrence says if people are going to go to sporting events, theatres, or concerts, there needs to be a way to ensure the gathering is safe.
Lawrence Gostin: But if you don’t have a way to authenticate whether somebody is vaccinated, you really don’t know if the person’s standing or sitting next to you is safe.
Céline Gounder: Just to play devil’s advocate here. And I don’t actually believe this, but if you have been vaccinated, why should you care if the people around you have not been like, say you go, I don’t know, see a play on Broadway, and you’ve been vaccinated. Why does it matter if all the other people in the theater are unvaccinated?
Lawrence Gostin: Well, I would answer that in a couple of ways. Firstly, even vaccinated people can get breakthrough infections. It’s rare. And particularly with the messenger RNA vaccines, but you can, even if you’ve been vaccinated, become sick, it’s low likelihood, but you can.
Céline Gounder: Lawrence also thinks there’s a benefit for people who aren’t vaccinated. He says a vaccine credentialing system would let them know in which environments they’d be safe.
Lawrence Gostin: So, even though a person has not been vaccinated, I still care about them, and I care about their health, and I want to protect their health and safety just as I want to protect the health and safety of people who were fully vaccinated.
Céline Gounder: Many universities have already said they’re requiring proof of vaccination to attend classes and live in dorms this fall. Some private businesses are also considering similar requirements for their employees and patrons. And they have the right to do so, according to the federal Equal Employment Opportunity Commission or EEOC.
Lawrence Gostin: The EEOC has said that employers have the entire right to require proof of vaccination as a condition of return to work. They’ve also stated that this could happen now even under an emergency use authorization of vaccines. So for example, you know, lots of workplaces in lots of stores and restaurants, most of them, in fact, required everybody to wear a mask to go in. And that that’s perfectly lawful, you know, “no shoes, no shirt, no mask, no service.”
Céline Gounder: What private businesses can’t do is discriminate based on things like sex or race.
Lawrence Gostin: But vaccination systems, you know, don’t rely upon race or disability or sex or any other protected status. So basically employers and businesses have very wide discretion in setting rules in the workplace that are reasonably related to safety.
Céline Gounder: We do see inequity and vaccination and some of that is driven by access. So couldn’t this indirectly create inequity?
Lawrence Gostin: Yes. Of all the ethical arguments, um, that are posed against vaccination passports. The one I take most seriously is equity. The only way that proof of vaccination systems can be can be ethically justified is if everybody who wants a vaccine can get a vaccine.
Céline Gounder: Lawrence says if businesses and institutions are going to require someone to get vaccinated, they need to provide those resources. Things like paid time off to get the shot, or covering childcare costs so a parent can get to their appointment.
Lawrence Gostin: In other words, we have to take affirmative steps, to be fair and equitable. Equity can’t be a side issue. It has to come front and center.
Céline Gounder: But some states are trying to stop these systems before they take shape. Florida recently passed a law banning private businesses from requiring proof of vaccination. This has set the state on a collision course with the cruise line industry. Some of the earliest outbreaks of the pandemic happened on cruise ships, and many believe vaccine requirements are the only way for the industry to restart this summer.
The Biden administration has said it will not implement a federal vaccine registry or certification system. This means that whether vaccine credentialing systems are put into place and how they’re used will vary from state to state. While Florida may be trying to block businesses from requiring vaccines… New York state has started rolling out its own vaccine certification system. It’s called Excelsior Pass.
Albert Fox Cahn: The basic version is that a user will search for their identity on the Excelsior Pass website that will be cross correlated with the state’s vaccine registration database.
Céline Gounder: Albert Fox Cahn again.
Albert Fox Cahn: And once you have that, you then can either. Store this pass, which is, you know, your name, your birthday, and a QR code, as a photo on your phone, you can print it out or you can save it in the Excelsior Pass app, which is a separate app for iPhone and Android.
Céline Gounder: Excelsior Pass is a voluntary way people in New York can show proof of vaccination or negative COVID test results. It was developed with IBM.
Albert Fox Cahn: So we’ve seen it at a Yankee Stadium, at the Barclays Center, in Madison Square Garden.
Céline Gounder: It’s also been in use at some private businesses, like offices or restaurants. Albert was curious about how the passes worked. So he started to play around with it.
Albert Fox Cahn: I realized just how easy it would be to fake. And so I went on Twitter, and I just said, who here would be comfortable with me trying to access your Excelsior Pass, and someone who I’ve never met, I don’t know them in real life, just on social media, said that he would be happy for me to do that.
Céline Gounder: Albert looked through this volunteer’s social media feed… made some Google searches… and entered the information.
Albert Fox Cahn: It took me 11 minutes from the time he gave me consent to time. I was accessing his Excelsior Pass.
Céline Gounder: Theoretically, Albert could have downloaded that QR code to his phone and used it as proof that he was vaccinated. It’s worth noting that the Excelsior program says venues should check ID with the QR code to make sure it’s the same person. But it still means the pass could be easily faked or stolen.
Céline Gounder: So, is this any more fraud proof than say the CDC paper cards?
Albert Fox Cahn: Well, I mean, I have terrible handwriting, so I honestly would have taken longer to forge that CDC card.
Céline Gounder: Albert is also worried about what happens to this information after it’s collected.
Albert Fox Cahn: IBM is always quick to say that they don’t use location services on the phone, but they don’t need that data to figure out where you are because the people who are scanning your app as part of the registration process, have told them the location where they’re using it.
Céline Gounder: Albert downloaded the scanner app to see how it works.
Céline Gounder: So while the app on a smartphone itself may not track someone’s movements… the scanner data could possibly reveal when and where that person’s Excelsior Pass was used.
Albert Fox Cahn: So this means that if we were to incorporate Excelsior Pass into the subway system, into a lot of commercial activities, every time you pass that sort of vaccine bouncer at the entrance to the supermarket or to tap into the subway station, it will now have that location record.
Céline Gounder: Albert and others worry this health data could be used by law enforcement. He says similar location data has been used by Immigration and Customs Enforcement to detain and deport undocumented immigrants.
Albert Fox Cahn: I think it’s important to highlight that American privacy laws generally allow police access to information as a matter of default.
Céline Gounder: In December, New York state Governor Andrew Cuomo signed a bill into law barring law enforcement from accessing contact tracing information from public health sources.
Albert Fox Cahn: But that law, unfortunately, wouldn’t apply to this sort of vaccine app. And so we are creating this vast reservoir of data where the state is essentially asking us to just take them at their word that nothing bad will happen, but there’s no reason why we should do that. And that just layer of uncertainty is just to me completely incompatible with the trust that we keep hearing is paramount from public health experts that know our partners continue to stress that the thing that is most important in battling vaccine hesitancy is building trust in a, as many communities as possible, but when you’re creating this new layer of uncertain tracking, it does just the opposite.
Céline Gounder: In May, lawmakers in New York presented a bill that would require the state to protect the privacy of someone’s information collected by Excelsior Pass. It would also prevent law enforcement from accessing any information collected by the registry. We’ll hear about another system that may be more secure and why these requirements are so onerous for people in the Global South. That’s after the break.
Céline Gounder: JP Pollak is the co-founder of the not-for-profit Common Project Foundation. He’s also an Assistant Professor of Clinical Epidemiology at Weill Cornell Medical College in New York City.
JP Pollak: I spend most of my time working on helping people get to get access to their health information. Whether for participating in research, for improving their care or for using them with various health and wellness apps.
Céline Gounder: There are serious privacy and civil liberty concerns when it comes to any vaccine certification system. But there’s also an opportunity to improve access to medical records.
JP Pollak: Prior to COVID, there was not really a great use case for getting access to health information on your mobile phone. This particular use case is really the first time that folks have wanted to get access to this data in digital form and put them on our devices.
Céline Gounder: COVID vaccination cards are just the latest bit of important health information Americans need to keep a record of.
JP Pollak: It’s very difficult today to get access to all of your health records in one place, unless you happen to receive all of your care from within the same health system. One such use cases, people with complex case histories, being able to pull their records from all of the different places where they receive care and put it in one place on their phone.
Céline Gounder: JP’s team at the Common Project developed an app called Common Pass to show someone’s test results or vaccination records. Common Pass isn’t a form of identification. It’s just a yes or no signal if someone has met the venue’s requirements.
JP Pollak: So the idea is that I might not necessarily want to turn over my immunization record or my COVID-19 lab test results to my airline or to a border patrol agent. What I really want to convey is that I’ve met your entry requirements, and it’s okay for me to proceed.
Céline Gounder: Common Pass verifies the personal information someone inputs and cross checks it against the requirements to travel to a certain country or enter a sporting event, for example. It then generates a unique QR code that can be printed out or shown on a smartphone.
JP Pollak: One of the great things about this sort of privacy preserving methodology is it actually addresses some of the concerns around access to vaccination, intent to be vaccinated, things along those lines. If say the entry requirements for a particular country are a negative COVID-19 PCR test within the last 72 hours or an up-to-date immunization, being able to provide one or the other of those, and not necessarily having to share which, is sort of an effective way to help people maintain some of their privacy in these times.
Céline Gounder: JP says it’s still early days for these initiatives. Standards need to be established so that vaccine records are recognized by all the entities requiring them. The desire to travel and reopen the economy may speed up adoption.
JP Pollak: And I think that we’re likely to see regional rollout of similar sorts of initiatives and vaccination passes, particularly for this international travel use case as we get through summer, and on one hand, folks are eager to start traveling again and on the other countries are eager to have tourists come visit and start reinvigorating those sectors of the economy.
Céline Gounder: The United Kingdom and EU countries are requiring travelers to show proof of vaccination to enter. That might not sound like a big deal for someone who’s vaccinated and living in the United States… but it also means much of the world won’t be able to travel.
Fatima Hassan: You’ll be able to travel to my country, and none of us in South Africa will be able to travel to your country. In fact, we’ve been put on a list of at least a hundred countries. It won’t allow people from South Africa to travel.
Céline Gounder: This is Fatima Hassan, the founder of the Health Justice Initiative in South Africa.
Fatima Hassan: So British and German and Australian and Canadian tourists will be able to come to South Africa because they’ve received their vaccine. And all of us are just going to be waiting for vaccine appointment. So, it’s kind of perverse.
Céline Gounder: South Africa’s vaccination rollout is just starting… and like many less wealthy countries, South Africa can’t get the vaccines it needs to cover its population. Fatima says these vaccine requirements have become de facto travel bans for much of the world.
Fatima Hassan: So you create a travel restriction on a large section of a population of the world who basically are being told, “If you can’t access a vaccine and you don’t have proof of vaccination, you can’t travel.” Despite the fact that it’s not your fault, or it’s not your choice.
Céline Gounder: Vaccine hoarding by the United States and other wealthy nations have made it impossible for countries like South Africa to access supplies. And while there is some support from the Biden administration, there is still a long uncertain road ahead on whether or not low- and middle-income countries will be able to manufacture vaccines locally. Even if countries in the Global South can access vaccines, there’s another question — is this the “right” vaccine?
Fatima Hassan: The vaccine selection of many different countries is so, you know, to put it mildly, all over the place. Some countries that are using two different vaccines, some are using four different vaccines, because basically there’s a scramble for vaccines supplies, so you’d take whatever you get. And so we are concerned that the countries are saying, “well, we don’t recognize the Sinopharm, Sinovac or Sputnik vaccine. We only recognize, I dunno, as an example, Pfizer or J&J.”
Céline Gounder: Vaccine requirements don’t just affect someone’s ability to take a vacation or see family abroad. It can also interrupt employment opportunities and students’ ability to attend university.
Fatima Hassan: Some of them are now having to defer the educational opportunity or a scholarship or a fellowship, so it has a huge sort of ripple effect.
Céline Gounder: Fatima says the situation has left her disheartened.
Fatima Hassan: I can’t believe then in the middle of a pandemic, this is the response from governments who had promised solidarity. This is the response from global leaders who had promised empathy and compassion, and a lot of support at the beginning of this pandemic, but I’m also enraged and I’m angry because I’ve been through this before. You know, we sold this at night today. HIV/AIDS crisis in South Africa in the late 1990s and the early 2000s, I was, you know, part of a group of people that were working on affordable access to HIV/AIDS medicines. And we saw the suffering and the death at that time. And we never thought that this would happen again in our lifetime, but here we are twenty years later, having to fight the same battles, the same arguments, the same drug companies around access for people in the Global South. And so it shows to me that what has happened in the last twenty years is that people don’t actually value life in the Global South.
Céline Gounder: Fatima sees South Africa’s experience with HIV/AIDS as a cautionary tale for COVID vaccine certificates. Many countries banned people living with HIV from traveling internationally. And vaccine requirements have been used in the past to prevent people living with HIV from working in industries like airlines.
Fatima Hassan: So the situation with COVID that we have to guard against is on the one hand we want to encourage, large-scale vaccination because we do believe in the science and the evidence and the safety and efficacy of vaccines. But the requirement in this stage of the pandemic, when you still have this global disparity in access to supplies means that the impact of that requirement of having a vaccine is basically something that the majority of the world’s population will not be able to meet. And that requirement is actually going to cause further harm, and is going to cause further prejudice.
Céline Gounder: Vaccines are a safe and reliable way to prevent the transmission and severity of the coronavirus. Proof of vaccination has been shown to be effective in accelerating the transition from masks and other mitigation measures to a fully open society again. But there are a lot of considerations, including privacy and equity, that need to be addressed first.
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I’m Dr. Celine Gounder. Thanks for listening to EPIDEMIC.