Immunology and identity: The implications of immunity passports
Social scientist, Dr Richard Milne, explores the role of immunity passports in the time of a pandemic
Historically, every epidemic and pandemic, has presented novel challenges and created new roles for governments, clinicians, companies, scientists, and the public. For example this cartoon shows (not entirely sympathetically) officials of the London Board of Health ‘tracking and tracing’ cases of cholera in 1832, suggesting they are as motivated by their 20 guineas a day, as much as by their concern for public health.
In the 21st century, the impact of Covid19 is leading to the emergence of a new identity. One based on our interactions with a combination of digital, medical, immunological and genomic tools, and information. So called ‘immunity passports’ form one potential pillar of this identity.
Living in pandemic times
The coronavirus pandemic has had significant and traumatic social and economic effects around the globe. The vast majority of countries have implemented some kind of lockdown measures, albeit with varying levels of stringency.
By mid-May 2020, 94% of the world’s workers were living in countries with some level of workplace closures or restrictions; schools were closed and public transport systems disrupted. While lockdown measures have eased in many places, for most of us life has by no means returned to ‘normal’; our work, school and social life are still characterised by social distancing measures. For example, Google community mobility data, shows that although levels of activity have begun to pick up, they are still below ‘baseline’ or what would have been normal life pre-coronavirus.
The question and the challenge remains then, how can we continue and extend the easing of lockdown? And how do we do so in a way that minimises the impact on the rate of infection, while enabling our social and economic lives to start moving?
Technology to the rescue?
From the earliest stages of the pandemic in Wuhan, science and technology have consistently been given a central role in not only understanding and treating the virus and its effects, but in tracking and controlling its movement; analysing the effectiveness of lockdowns; and potentially in shaping a post-Covid society that gives us a route through lockdown, but which may look radically different from the pre-pandemic world.
China, for example, was the first to use a smartphone-based tool for indicating health status, which was essential for allowing people to travel within, and ultimately beyond, the containment zone. The AliPay HealthCode provides users with a colour-coded health status based on their travel history, time spent in outbreak hotspots and exposure to potential carriers of the virus. Other countries, including the UK, have launched or attempted smartphone based contact tracing systems, with varying degrees of success. Singapore augments its smartphone-based approach with standalone bluetooth devices that are distributed to those without smartphones. In some countries, including South Korea, Russia and Ukraine, a smartphone app tracks the movements of users to ensure they are not breaking quarantine. In Karnataka, India, the Quarantine Watch app requires individuals under quarantine to take a GPS-tagged selfie every hour between 7am and 10pm.
Alongside government efforts, tech companies such as Google and Apple have developed bluetooth-based contact tracing systems. And digital health companies including FitBit, and the smart ring company Oura, are exploring the possibility of AI-based detection of pre-symptomatic signs of infection, based on data from wearables such as elevated heart rate or changes in breathing patterns. However, in addition to their potential public health value, these technological approaches have brought public health ethics to the fore. To what extent do we accept surveillance of our movement and our health in a time of emergency? And what are the consequences of both being included, and of being left out of these systems? In the case of the Ukrainian quarantine app for example, the NGO Human Rights Watch has highlighted cases of people being unable to enter the country, and being forced to spend nights outside in the disputed zone between Ukraine and Russia, simply for lacking the necessary technology to install the app.
Test, test, test
Underpinning the potential value of much of this digital technology however, is biology — particularly testing for present or past coronavirus infection. As we’ve all heard since the beginning of the pandemic, testing is central to the public health response — from the World Health Organisation’s exhortation to “test, test, test”, to the ever increasing and often-contested UK Government targets for daily test figures.
By the 6th July 2020, over 10 million tests for coronavirus had been either processed or sent out in the UK. Of these, the majority are tests for active infection, antigen testing conducted in hospitals, Public Health England labs, or community programmes. A million or more antibody tests have also been carried out.
Whereas the swab antigen test can identify active infection, antibody testing can be used to establish whether someone has previously been exposed to the SarS-CoV-2 coronavirus. They can, in theory, be used from a week or so after the infection — although recent research suggests they are more accurate at least two weeks after infection. In the early stages of the epidemic there was a proliferation of tests purporting to offer antibody results based on analyses of blood drawn from a finger prick. In the UK companies including Superdrug and Babylon Health sold such tests direct to consumers, but following intervention from the MHRA (the UK regulator responsible for medical devices) these tests have been withdrawn, and the only tests currently approved for use rely on clinical blood draws.
Antibody tests can be used to estimate the proportion of a population that has been exposed to the virus. A study of a cohort of 61,000 people in Spain estimated that around 5% of the population had been infected with coronavirus, with higher levels in major cities such as Madrid.
In the UK, the Office of National Statistics’ Coronavirus Infection Survey estimates that 6.3% of people in the UK carry Covid-19 antibodies — around 2.8 million people, while data from blood donors suggests that this number varies significantly by region.
In addition to the value for public health surveillance and planning, it has been proposed that information on antibody status may have value for countries, employers, and individuals, in the form of certification that an individual has contracted and recovered from Covid-19, and that consequently, they can be considered to have some level of immunity.
The immunity passport
The notion of the immunity passport, certificate or license refers to a “digital or physical document that certifies an individual has been infected and is purportedly immune to SARS-CoV-2” (Phelan 2020). It was first suggested in France and Germany in March 2020, before being floated in early April by UK Health Secretary Matt Hancock at his first press conference after he himself had recovered from Covid-19. The concept was then explicitly included in the remit of the UK Government’s testing lead, Dido Harding. A number of other countries have at least explored the idea — although only Estonia, to date, is apparently trialling the concept.
Despite the lack of government action, a number of companies — both start-ups and those who have redirected efforts in other areas — are working to meet the potential demand for ‘immunity passports’, often combining a record of test status with a digital ID platform for verification. For example, the company Prova draws on the expertise and capacity of the molecular diagnostic company YourGene, but is a spin-off from the financial tech company Hooha. Some of these companies, such as Covi-Pass and hVivo, have been reported to be in discussions with national governments about the implementation of immunity certificates, but they are also aiming to serve the private sector. Employers such as Ernst and Young and PwC are thought to be exploring the potential for implementation, while other immunity certification companies are targeting the travel, hospitality or events industry.
Harms and benefits
So immunity passports are certainly garnering interest, if not yet moving all the way to application. This might have some value, particularly economically, but such passports are problematic for a number of ethical, social and scientific reasons.
Matt Hancock’s statement set out the main draw of the immunity passport. At a time of unprecedented restrictions on everybody’s freedoms, immunity passports have the potential to finesse and nuance the brute force of a total lockdown, and to stratify and target measures. In economic terms, recognising that some people may no longer be at risk of infection may allow parts of the economy to start moving in a more normal way. It might enable employers to place staff at least risk in positions of greatest exposure, whether in a health or social care setting, or those in customer-facing roles such as transport and retail workers. It may also allow a better allocation of resources to protect those who remain at greater risk, including targeting vaccination policies if, and when, that becomes possible.
Socially, certifying antibody status might provide some people with increased social privileges, for example to visit bars, restaurants or venues without the need for social distancing measures. In the USA, the owner of the New York Knicks and Madison Square Garden, James Dolan, has already floated the idea of using some form of antibody certification to hold an in-person benefit concert for New York — offering to pay for testing for all those who bought tickets. It has therefore been argued that, in ethical terms, immunity certification may fulfil the public health principle of the least restrictive alternative — avoiding unnecessary impositions and restrictions on individuals who are neither at risk nor who pose a risk to others.
A historical precedent?
In order to better understand the benefits and negative consequences of immunity certification, it is worth considering what this might look like in practice. Although no such programmes are yet up and running, there are historical parallels which can be informative. Perhaps the best described, and most relevant, is that of early 19th century New Orleans, captured in the work of the historian Kathryn Olivarius.
Olivarius describes how newcomers to Louisiana and New Orleans were faced with the threat of yellow fever, at the time thought to be associated with the bad air or ‘miasma’ resulting from the heat and filth of the growing city. Yellow fever was fatal for half of those infected, and was considered a “stranger’s disease” strongly associated with “unacclimated” immigrants from the Northern US states and Europe.
For these new arrivals, at least those who were white and male, encounters with yellow fever presented both peril and promise. If they survived, it opened up access to what Olivarius terms immunocapital, in the form of funding and support not available to those who were not acclimated. Life insurance, for example, was cheaper and more readily available to those who had successfully acclimated, as were bank loans. For women in high society Louisiana, expected to raise a family, acclimation was a pre-requisite for marriage.
As a result of these benefits, people were both self-motivated and exhorted in the press to take responsibility for becoming acclimated, coincidentally removing pressure for public health action on the part of city councils. However, the benefits of immunocapital were only accessible to those already most privileged. In contrast to white immigrants, for whom immunity became a source of capital and power, for black slave residents — who were considered without evidence to be more resistant to yellow fever — acclimation simply increased their value as property, benefitting their owners while often placing them in some of the most dangerous or difficult environments.
The case of New Orleans shows how immunity can become a source of privilege. It also shows the potential for social stratification on the basis of immunity, to map on to, and exacerbate, existing inequalities and injustice.
Lessons for today
Discrimination
The issue of immunity passports today draw into focus a number of concerns, as they plot existing social and economic fault lines in our society — highlighted by the impact of Covid-19 on black and minority ethnic groups, and the inequalities and forms of discrimination that have resulted in the Black Lives Matter movement.
By its nature, stratifying the population based on the existence of an antibody response involves some level of unequal access to goods and services, including in relation to employment. Although not necessarily a bad thing, any form of discrimination carries the risk of unfairly affecting some groups or individuals. For example, it is conceivable that some employers may come to discriminate on the basis of what has been described as ‘immunological fitness’ — recruiting workers whom they feel are less likely to fall ill, or to pose a risk of infection to other staff or the public. Such an immune-certified workforce might represent an advantage, including to businesses in sectors like tourism, hospitality or in the care sector.
In such circumstances, individual employees’ freedoms may be practically restricted as they may feel compelled or coerced to both take a test and to disclose the result. Those on zero hours contracts meanwhile, might find themselves unable to work as a result of testing negative, with only minimal state support provided. More broadly, there may be an expectation that those engaging in social activities will to be able to demonstrate their status, or be considered to be concealing something.
It is also the case that the burden of any such discrimination is not likely to be equally distributed, and is likely to fall on those who are already socially marginalised or disadvantaged. In a context where the effects of Covid-19 are felt disproportionately by Black and minority ethnic communities, or by those with existing health conditions, becoming ‘immunoprivileged’ does not bear the same risk for all.
Equity
Access to antibody testing requires certain resources. We’ve already seen this in the UK with regards to swab testing — the early ‘drive through’ testing facilities established to expand testing capacity were often located in out-of-town car parks near major cities, making it difficult for those without cars or living in rural or remote areas to access testing. In the case of antibody testing, any system that requires individuals to pay, or that is based on employer contributions risks excluding those who are economically disadvantaged or out of work, while those linked to smartphone verification systems may impact the already digitally-excluded.
Perverse incentives
Thirdly, state or corporate policies supporting immunity certification risk creating perverse incentives. There is an important distinction from vaccination certificates, such as that for yellow fever — the carte jaune that some countries require for entry. As Alexandra Phelan has highlighted, vaccination certificates create a privilege associated with vaccination, and the increase in demand for vaccination associated with this benefits everyone. Antibody certificates in contrast, do the opposite.
As for new arrivals in early 19th century New Orleans seeking to acclimate to make their fortune, antibody certification could create a perceived advantage in increasing one’s exposure to the coronavirus. This both increases the risk to individual health, and undermines public health efforts to control spread. Short of deliberate exposure, linking antibody certification to employment, goods or services also creates an incentive for sero-negative individuals to forge or falsify samples or documentation, particularly given the proliferation of certification systems — again, increasing the risk to themselves and the likelihood of population transmission.
Back to the science
Of course, these discussions are all based to some extent on an assumption that the science of Sars-CoV-2 antibody testing is or will be robust enough to actually support an immunity passport system. Currently, reviews suggest that antibody testing is hampered by small studies that provide little information about the accuracy of tests outside clinical settings, particularly among people with mild disease or with no symptoms. Although the nature of Covid science means such reviews are out of date almost as fast as they emerge, they suggest that any antibody test would currently have limited value for a certification programme. The low overall proportion of the population thought to be infected presents the risk of a high rate of false positives, and the consequent incorrect reassurance of people who have not been exposed to the virus, but are told they have been.
Furthermore, as the World Health Organisation highlighted as far back as April 2020, we do not know with any certainty what level of immunity, or what type of immunity, is indicated by the presence of antibodies. As Dido Harding put it in a UK Government press conference in June, we currently know that “if you have antibodies, you have antibodies”. This will likely become clearer over the next few months, but at the moment, we risk proceeding — as countries, companies and individuals — as if this is already known. Again, this has risks not only for those who assume they are immune but are not, but also for the wider effort to reduce transmission.
Conclusions
Immunity passports are one of a range of scientific and technological approaches being considered and debated by governments and companies as a means of helping society establish a post-Covid normality. Although in many ways they may be an ethical way of restoring social and economic freedoms to individuals, and supporting the economy, they also present a range of concerns associated with their potential to exacerbate existing inequalities and undermine public health efforts. Although the use of immunity passports is not currently well supported by the science, either in terms of the accuracy of testing or the implications for immunity, this may not be a barrier for some. A potential private market for antibody testing for employers and individuals should be closely monitored, with the option for ensuring that any outcomes from their application are controlled through regulation.
Dr Richard Milne is interested in how genomics and new diagnostic technologies shape our concepts of health and illness, and what that ultimately means for the care of current and future patients. He is a Senior Social Scientist in the Wellcome Genome Campus Society and Ethics Research group, which is part of Connecting Science and funded by Wellcome.
Further reading
Ada Lovelace Institute (2020) International Monitor: Public Health Identity Systems
Togni, G. et al. (2020) Imagining Life with “Immunity Passports”: Managing Risk During a Pandemic
Kofler, Natalie, and Françoise Baylis. (2020) Ten Reasons Why Immunity Passports Are a Bad Idea. Nature 581 (7809): 379–81.
Olivarius, Kathryn. (2019a.) Immunity, Capital, and Power in Antebellum New Orleans. The American Historical Review 124 (2): 425–55.
Persad, Govind, and Ezekiel J. Emanuel. (2020) The Ethics of COVID-19 Immunity-Based Licenses (‘Immunity Passports’). JAMA 323 (22): 2241–42.
Phelan, Alexandra L. (2020) COVID-19 Immunity Passports and Vaccination Certificates: Scientific, Equitable, and Legal Challenges. The Lancet 395 (10237): 1595–98.
Voo, Teck Chuan, Hannah Clapham, and Clarence C. Tam. (2020) Ethical Implementation of Immunity Passports During the COVID-19 Pandemic. The Journal of Infectious Diseases.
Weinstein, Milton C., Kenneth A. Freedberg, Emily P. Hyle, and A. David Paltiel. (2020) Waiting for Certainty on Covid-19 Antibody Tests — At What Cost? New England Journal of Medicine.
