Responding to Covid-19: The problem with immunity passports

This is the sixth article in a series on issues arising from, and responses to, Covid-19 in the UK and beyond. Here I cover some of the issues that need to be considered as part of discussions on the value and potential impact of ‘immunity passports’.

Discussions on immunity passports or certificates are increasingly being played out in the media. And ‘systems of certification’ are being worked on in government.  The aim is to potentially ‘liberate’ individuals to resume going about their day, and their work, without the requirements of social distancing and lockdown.

On the plus side, it would mean those with immunity could get back to work and reengage with their lives. But, what is clear is that the science and evidence for the efficacy of these antibody tests is poor, and the risks of predictable though unintended consequences are great.

This article is grounded in a panel discussion hosted by the Ada Lovelace Institute. It is part of the work the Institute is doing on health identity systems. The session was Chaired by Imogen Parker, Head of Policy, Ada Lovelace Institute. Panelists included:

• Danny Altmann, Professor of Immunology, Imperial College London
• Virginia Berridge, Professor of History and Health Policy, London School of Hygiene and Tropical Medicine
• Robert West, Professor of Health Psychology, University College London
• Edgar Whitley, Associate Professor of Information Systems, London School of Economics

The science of immunity passports

Covid-19 is a new virus and there remain a lot of unknowns. It was only in the last few weeks in the UK that the new symptom of the loss of taste or smell became included in the list of possible symptoms.

The fundamental issue is we don’t know if having the antibodies that means you’ve had Covid-19 confers immunity, and if it does, for how long. Another complicating factor is that not everyone who has had Covid-19 will go on to develop antibodies.

On the testing side, issues remain. Of the tests currently in development or in use, there is wide variation in reliability and sensitivity. In addition, there may well be cofounders like the common cold virus which mean you could test positive for the antibodies without having had Covid-19.

But even if tests that were 100% reliable and have a high level of sensitivity were developed, issues remain.

The social context

A useful framework for thinking through the social issues with regards to immunity certificates is APEASE, which Professor Robert West spoke through. It covers the following:

• Acceptability – to what extent would the use of immunity passports or certificates be acceptable; how would be embed trust and fairness in its deployment;
• Practicability – could it be rolled out at scale?
• Effectiveness – would it achieve the intended objectives? Here there are a number of issues to consider including how predictive the results are of lasting immunity, and would there be widespread uptake;
• Affordability – who pays? Would it be health services, employers, individuals?
• Spill-over effects – would it result in unintended consequences such as social division? I expand on at least a few of these below.
• Equity – primarily would the introduction of an immunity passport system increase or decrease existing inequality? What might it mean for people working in vulnerable occupations such as transport or health and care, or specific social groups such as those with weakened immune systems who are required to shield?

As noted in the discussion, it is not until these issues have been addressed that we can start to have a meaningful conversation.

The historical context

To understand some of the issues with the idea of immunity passports or certificates for Covid-19 today, it’s essential to understand the historical context. This provides important insight into just how problematic singling out certain groups within populations can be. Historically, we know that these certificates tended to exacerbate inequalities and social division, and led to many taking creative ‘workarounds’ to the various requirements.

Yellow fever is a viral disease caused by mosquitoes. While it will be a relatively mild disease in many, some will go onto become very ill, and indeed some will die. New Orleans in the 19^th century introduced immunity certificates for yellow fever. Without one, you were unable to find a wife, a job, somewhere to live. Newly arrived migrants would deliberately get infected to enable them to engage with society once they were better. Some would have died in doing this. And the science was poor with limited understanding of how long someone would have immunity.

In the US in the 1930s, in some states it was not possible to get married without demonstrating you were free from syphilis. Generally only the bridegroom was required to demonstrate this. It could take some years to get testing. So, what was an engaged couple to do? As expected, some went to other states where the test wasn’t required to get married. Also, testing at the time was unreliable resulting in many unnecessary treatments. It also created stigma.

There was some change in the approaches taken with testing for HIV status. Tests first became available in the mid-80s. In the discussions at the time, there was more on an emphasis on human rights and reducing stigma. However, testing positive, or even having a test in itself, could trigger a whole host of issues including denial of health insurance. And stigma remains with gay men in many countries not being permitted to donate blood even with testing to demonstrate an HIV negative test.

The potential for unintended consequences

It doesn’t take much to identify some potential consequences of immunity passports for Covid-19.

Putting the science to one side, there could be some positives. A return to school, university, or work for many. Or little need to socially distance and restrict their lives in ways we’ve all been doing over the last few months.

But it’s easy to see where there are real risks for those without an immunity passport:

• there will be a proportion of people who deliberately become infected with Covid-19 to enable them to return to work;
• an inability to access health insurance, travel insurance and so on;
• an inability to travel due to border requirements for countries who may introduce widespread requirements for immunity passports;
• denial of certain services. For example, if it became a requirement to use public transport or to enter shops;
• preferential treatment for those who have ‘immunity’ from Covid-19 in the workplace;
• further disenfranchisement of those at high risk if they were to become infected and the need to shield; and,
• there’s an opportunity cost. Focusing on immunity passports could divert attention away from meaningful interventions like track and trace.

I came across an article in the New York Post on singles flaunting their antibody test results in their online dating profiles.

There will be many others I haven’t considered here. And the introduction of new technologies can have unpredictable consequences for wider society. What we know from even a cursory glance at the history of science and technology, while some of these can be positive, this is by no means always the case.

There remains a real risk that the introduction of something like an immunity passport would lead to further health, social and economic inequalities – the haves being those with immunity, the have nots, those without, particularly if it means they can’t access work, school, services.

Conclusion

It’s early days. The science is not there yet. The evidence remains weak. The introduction of such schemes may have a host of unintended consequences. There’s an urgent need for a wider public discussion, in the UK and globally, and to learn from history on both the potential opportunities and harms.