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

List of co-authors: De Togni, G.; Boydell, N.; Chan, S.; Erikainen, S.; Ford, A.; Ganguli-Mitra,

A.; Lawrence, D.R.; Montgomery, C.; Pickersgill, M.; Richards, R.; Sethi, N.; Swallow, J. (All

authors are based at the Centre for Biomedicine, Self and Society || The University of

Edinburgh || Scotland, United Kingdom).

Keywords: COVID-19, Pandemic, Risk, Immunity Passport, Accessibility, Vulnerability,

Inequality.

Word count: 1,557 words.

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.

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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). PHE (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 (Ibid.) 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 “immunodeprived” versus “immunopriviledged”

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

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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:

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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

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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

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potentially be penalised by these innovations. Until these conditions are met, we cannot

recommend the introduction of so-called “immunity passports”.

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