Don’t create a world of immunity haves and have-nots

On November 23, Qantas CEO Alan Joyce said his airline is considering a rule requiring passengers to get a coronavirus vaccine before they can board its planes. Joyce added the idea was being discussed in a broader conversation among his peers, although the International Air Transport Association, the industry’s lobby group, called the idea “a bit premature”. Premature as it may be, similar ideas — such as what has been referred to as immunity passport — have been spoken of in the context of the pandemic, and as vaccines begin shipping, it is likely to take centre-stage soon.

There are legal and practical precedents for what Joyce suggested, known as vaccination certificates recognised by the World Health Organization’s International Health Regulations (IHR). At present, the sole universal disease recognised is the Yellow Fever — passengers arriving from affected regions (mostly African and South America nations) or travelling to them may be required to produce them. Covid-19 vaccination certificates could be included in revised WHO recommendations under its “public health emergency of international concern” guidelines or any of 196 member-states could ask for an inclusion of it under IHR.

But mandating these certificates at any level, international or domestic, comes with ethical and economic implications till vaccines become affordable, accessible and are in adequate supply for all. Assessments of vaccine supply deals suggest high-income countries have secured the bulk of the supply available till the end of the next year — some have enough commitments to cover their populations twice over. Once they do receive a vaccine, low and middle-income countries (LMICs) are likely to take longer to inoculate their large populations.

The lack of adequate supply chain infrastructure and electricity can compound these challenges, as can typically endemic issues of corruption and domestic inequity that often afflict the Global South. WHO’s State of Inequality report in 2019 found that full childhood immunisation — possibly the closest example of vaccines that are a must

— coverage varies wildly in LMICs. In the 67 LMICs surveyed (excluding India and China), the median coverage varied from 51% to 83% for children under the age of one. In 16 countries, less than one in four children got full immunisation. In 11 of these countries, children in the richest quintile were twice as likely to be immunised as children in the poorest.

Pharmaceutical powerhouses such as India and China are likely to be able to minimise their disadvantage, but — at least in the case of India — estimates by experts suggest only about 30-40% of the country is likely to be vaccinated till the end of 2021. For populations that do not have widespread coverage, this could translate into lopsided restrictions on even essential travel. The difference between the immunity haves and have-nots will not just impact lives but also livelihoods. Covid-19 has exacerbated inequities. People who have had the most capital have had access to better health care at a time when most public utilities have been overwhelmed. People in white collar jobs have been able to quarantine, isolate and earn while working from home, while others have lost pay and employment as their workplaces shut.

Governments and businesses must chart a path out of this pandemic that minimises inequities. These conversations have begun in some of the richest countries, such as the United States where President Donald Trump had access to potentially life-saving coronavirus treatment that is out of reach for ordinary Americans. It is a conversation that has been reignited by the high prices of the most effective vaccine candidates, which cost up to 10 times as much as the cheapest. Bioethicists and philanthropists had indeed flagged the issue as poorer countries struggled with lack of political or economic leverage. India must evaluate any decision that could lead us to prioritise those with immunocapital because the ones without it will likely be the victims of choices they did not make.