Saturday, Nov 26, 2022

From Smallpox to Covid-19: The history of vaccine passports and how it impacts international relations

Regarding vaccine passports, the World Health Organisation (WHO) raised concerns surrounding the operational, ethical and diplomatic consequences of allowing certain individuals to avail of privileges that others face hurdles to access.

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As the global administration of Covid-19 vaccines escalate, several countries, non-governmental organisations and private corporations have announced plans to introduce a system of Covid immunisation certificates to facilitate travel.

Called vaccine passports, these documents will essentially serve as digital or paper-based certificates enabling anyone vaccinated against Covid to move across international borders.
They are designed to provide a private and secure way of checking who has been vaccinated, allowing them to present proof of the same.

The verification process typically involves two steps. First, a vaccination site provides a digital record or certificate with details of a person’s vaccination. That person would then either scan the certificate or manually upload a verification number onto an app or a website. They could then present that app or code to airlines, restaurants or other establishments to prove their vaccination status.

Currently vaccine passports gaining traction include the European Union’s Digital Green Certificate, New York’s state-backed platform Excelsior Pass, Common Pass, an initiative from the non-profit Commons Project Foundation, and IBM’s yet-to-be-released blockchain enabled certificate. Along with several vaccine passports introduced by individual airlines, the international Air Travel Association (IATA) has also called on the 290 airlines that it represents to sign up for its IATA Travel Pass. Similar to choosing between several credit cards for payments, customers will be able to shop around for vaccine passes, using different ones to avail of various services.

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Countries, trading blocs and airlines have stipulated their own parameters for these certificates, and a few will continue to require them in conjunction with a negative Covid-PCR test. However, despite those variances, the common consensus is that people in possession of a vaccine passport will enjoy greater access to freedom of movement across international borders than their non-vaccinated counterparts.

Earlier this year, an article published by the World Health Organisation (WHO) raised concerns surrounding the operational, ethical and diplomatic consequences of allowing certain individuals to avail of privileges that others face hurdles to access. Each country has its own definition of individual liberties and how they apply the use of these passports internally will vary in accordance with their laws and constitutions. As per a March 2021 research paper in the Lancet, failure to create a uniform system of vaccine passports to regulate cross-border movement could escalate diplomatic conflicts and widen the gulf between richer and poorer nations.

History of immunisation passports

The concept of requiring proof of immunisation to occupy certain spaces dates back to Edward Jenner’s development of the first known vaccine in 1796. Designed to inoculate people against smallpox, confirmation of having taken this vaccine was a prerequisite for travellers at the time, mostly pilgrims, entering towns such as Pandharpur in British India or going to Mecca for the Hajj. Continuing into the 19th century, this policy was widely implemented across the globe with the El Paso newspaper reporting that travellers entering the United States had to show either a vaccination certificate, a scar on the arm or a “pitted face” indicating that they had survived smallpox.


In an interview given to NPR, Sanjoy Bhattacharya, professor of history at the University of York, says the need to provide proof of vaccination intensified after the introduction of air travel in the 20th century. Till then, people infected with smallpox could easily travel to other countries and risk outbreaks in local populations. Thus, vaccination certification checks were enforced before travel “with forcible isolation at airports of any passengers considered to have dubious documentation.”

Vaccine certification checks are even codified under international law with the first protocols defined under the International Sanitary Regulations Act, adopted by WHO member countries in 1951. Since renamed the International Health Regulations (IHR) in 1969, this Act allowed member states to demand proof of vaccination as a condition of entry. While now yellow fever is the only disease specified in the IHR, the WHO has recommended that certain high-risk countries require travellers to provide vaccination certificates for diseases from which their population has not been sufficiently inoculated. For example, visitors to Pakistan and Afghanistan are recommended by the WHO to take adult doses of the polio vaccine before travelling due to the prevalence of the disease in those regions.

As of now, the WHO has maintained a stance against Covid vaccine passports citing the risk they pose in perpetuating global inequality, a lack of evidence on vaccine efficacy in terms of herd immunity and the substantial operational challenges that such a system would present.


Operational and Ethical Considerations

A number of scientific unknowns remain concerning for governments when evaluating the impact of Covid vaccines in stopping the spread of the disease. These include their efficacy in limiting transmission, especially for variants of the virus, the duration of protection offered by vaccination, the distinctions between different vaccines, whether or not booster doses are required, whether vaccines protect against asymptomatic infections and whether people who have antibodies should be exempt from vaccination. Simply put, no one knows how or if vaccines will prevent transmission and therefore organisations like the WHO and other human rights groups warn against the introduction of vaccine passports, lest people view them as an excuse for complacency. These uncertainties have the potential to cause serious diplomatic incidents especially if tourists from certain countries cause wide-spread outbreaks in visiting regions after being vaccinated via their national rollout programmes.

Furthermore, with several competing vaccination passes, the possibility of fraud is high. Researchers at cyber-security company Check Point have monitored hacking forums and other marketplaces since January 2021, when vaccine adverts first appeared. Everything from a vaccination certificate to a negative PCR test to a dose of the vaccine can be bought illegally online (it is unclear whether the doses offered are effective or not.)

Without a central database of vaccination records, a system that would be highly concerning to data-privacy advocates and national security hawks, not to mention a logistically herculean task, forgeries are inevitable. According to Check Point, countries can limit the number of forgeries by adopting a QR code system across all vaccine documentation. Even with those measures, however, barriers to implementation will exist for governing agencies and aviation bodies.

According to data published by IATA, international passenger traffic in 2021 is roughly 15% that of pre-covid levels yet one airline reports having as many agents on the ground as during peak summer levels because they have to check all the verification documents surrounding vaccination. However, despite these limitations, Professor Chris Dye, a leading epidemiologist at Oxford University stated on the Oxford University website that “an effective vaccine passport system that would allow the return of pre-Covid-19 activities, including travel, without compromising personal or public health, must meet a set of demanding criteria – but it is feasible.”

In addition to the practical limitations of a vaccination passport, there are ethical considerations in play as well. Currently, there is restricted access to vaccines worldwide, particularly in low-income and lower-middle-income countries. The WHO has warned that the inequitable distribution of the vaccine would deepen existing inequalities and introduce new ones as well. A WHO working paper outlining these considerations goes on to mention that “in the context of unequal vaccine distribution, individuals who do not have access to an authorised COVID-19 vaccine would be unfairly impeded in their freedom of movement if proof of vaccination status became a condition for entry to or exit from a country.”


Even within countries, certain groups are prioritised over others. In particular, low-income communities, rural populations, marginalised groups and younger people are less likely to be vaccinated than the general subset. “Beyond being a distraction from the task of vaccination, the pass could end up creating a two-tier society,” Israel Butler of the Civil Liberties Union for Europe, a human rights watchdog, told the Washington Post in response to the proposed system, noting that the passport had the potential of denying certain individuals’ access to public services.

However, legally, the precedent for vaccine requirements has existed in certain countries for over a century. In 1903, the government of Maine declared that no person without proof of smallpox vaccination was allowed to work at a lumber camp, a decision that was reinforced by the US Supreme Court in 1905, when it ruled that government entities could require vaccines for entry, service and travel, and that states could impose a fine on unvaccinated people. As historian Michal Willrich notes in his book Pox, this occurred around the time when Americans began to conceive of liberty not only as freedom from regulation, but also as freedom to meaningfully and actively participate in public life.


Similarly, public health professionals like Dr. Maya Peled Raz, an expert in health law and ethics at the University of Haifa, argue that with vaccine passports, certain trade-offs are necessary. “That may involve some damage to individual rights, but not all damage is prohibited if it is well-balanced and legitimate in order to achieve a worthy goal,” she told the New York Times. “It’s your choice,” she added of leisure activities. “If you are vaccinated, you can enter. As long as you aren’t, we can’t let you endanger others.”

Tit for Tat

In 2012, upon arrival in South Africa, 125 Nigerians were denied entry for lacking the required yellow fever vaccination documentation, of which 75 were sent home. The next day, Nigeria barred 28 South Africans from entering the country, and deported another 56 illegal immigrants. When searching through the annals of diplomatic history, examples like these are prevalent. According to a column by Max Fisher in the New York Times, countries tend to act in their own diplomatic interests, even when doing so would contradict logic or compromise morality.


The EU has long maintained a policy of visa reciprocity, an objective that the Union pursues in a proactive manner in its relations with non-EU countries. This means that when the EU is considering lifting visa requirements for citizens of a non-EU country, it takes into consideration the visa requirements imposed by that country on EU citizens. And while OECD countries are commonly known to have high entry requirements for citizens from Asia and Africa, those latter regions have the highest levels of entry restrictions themselves. A 2017 analysis of global dynamics in visa reciprocity show that only 21% of countries have asymmetrical visa requirements, with levels of reciprocity increasing exponentially since the 1990s. If a global system of vaccine passports is introduced, countries may determine which passports they accept on the basis of which countries accept theirs.

The notion of quid pro quo diplomacy in regard to Covid vaccine passports is perhaps best exemplified by China, who recently announced that it would expedite entry for foreign nationals who had received a China-made vaccine. This move has caused concern amongst several countries that do not offer the Chinese vaccine but have students and workers who were based out of China before the pandemic. Nicholas Thomas, associate professor of health security at the City University of Hong Kong, speaking to Foreign Policy, attributed this policy to China’s desire to bolster the standing of Chinese vaccines internationally. No vaccine from China has yet been approved by the WHO, and according to Thomas, this move would aim to “ensure that Chinese vaccines remain the preferred choice” for governments globally.

Regional power dynamics

The EU-backed Digital Green Pass would allow vaccinated EU citizens to travel freely within Schengen borders. However, while in theory freedom of movement within the EU is a fundamental priority, the process of establishing a standard for entry has been fraught. Countries such as Greece depend heavily on tourists, with tourism accounting for 20% of the nation’s GDP. Other EU nations such as Germany and France are less dependent on tourism and are therefore reluctant to ease restrictions. How to balance those interests has been a challenge for the trading bloc, which, while announcing the Green Pass, conceded that ultimately the decision of who to allow in or out would remain within the purview of individual nations. These discrepancies could prove challenging for countries such as Hungary which has largely been dependent on China-made vaccines. Under the Digital Green Pass scheme Hungarians travelling within the EU will still likely be reliant on the result of negative PCR tests to enter other countries. On that matter, Minister of the Hungarian Prime Minister’s Office, Gregele Gulyás, stated that “on the basis of reciprocity Hungary will not accept the certificates of countries which do not accept those of Hungary.” Sentiments such as these, while largely to be expected, will compromise the legitimacy of the EU, and undermine the very tenants of its existence.

Within Asia, Singapore and Malaysia attempted to establish reciprocal business travel bubbles in order to facilitate travel between the two countries, but that policy failed to significantly boost the targeted industries. Tourism is a core industry for much of ASEAN, with 51 million interregional visitor arrivals in 2019. Companies such as Air Asia have led the push for regional vaccine passports, citing the need to resume travel in order to enable operations and remain afloat. However, like with the EU, establishing regional standards may prove tricky, with several countries lagging behind on vaccination efforts and possessing different standards for vaccines than those of its neighbours. Singapore-based independent aviation analyst Brendan Sobie recently remarked to Nikkei Asia, that the regional vaccine certificate “will need to be pursued in tandem with other initiatives such as a multilateral pan-ASEAN air travel bubble in order to have a meaningful impact,” while acknowledging it is “a good first step in helping facilitate the resumption of travel between ASEAN countries.”

The haves and the have nots

While rich countries such as Canada have secured the majority of vaccine doses – Canada has 10 doses per citizen – others like Libya and Madagascar have yet to receive a single dose. Hippolyte Fofack, the chief economist at Afreximbank remarked to Rueters, that even if Africa had 100 billion dollars, it would be unable to access enough doses of the vaccine. Because the supply of vaccines is still limited, nations in Africa are reliant on wealthier countries to donate excess vaccines in order to meet domestic needs.

In February 2021, South Africa and India put forth a proposal to the World Trade Organisation to temporarily waive intellectual property rights around products that would contain and treat Covid-19 until herd immunity was achieved. This, they argued, would enable countries in the Global South to manufacture vaccines as soon as possible and confront shortages in supply. The proposal faced criticism from pharmaceutical companies, who argued that it would stifle innovation and restrict future advances in medicine and technology. However, access-to-medicine advocates countered that most of the research behind the Covid-19 vaccines was funded either by charities or national governments. Despite that, and despite the fact that the proposal had the support of more than 100 nations, countries home to major pharmaceutical companies such as the US and the UK, prevented this proposal from moving forward.

Generally, vaccines are produced by private companies that sell them domestically or to foreign governments withthe resources to pay a premium for them. In some cases, producers will make provisions for access in certain markets in exchange for early development funding or for allowing production to occur in a certain country. This system primarily benefits rich nations capable of developing the vaccine themselves or paying for early access. It also bodes well for middle-income countries like India and Argentina that have indispensable domestic manufacturing capacity. However, poor nations that are unable to compete in the open market are dependent on either participating in (often unethical) clinical trials or relying on hand-outs such as the complex vaccine sharing scheme, COVAX. Neither option is preferable. Countries that have enrolled citizens in early vaccine trials will still face long delays in receiving vaccine doses and those reliant on the COVAX scheme are required to pay widely fluctuating prices up-front while also assuming the entirety of the risk if the vaccine fails. With the introduction of vaccine passports, citizens from these countries will be restricted from international travel, especially those who are not digitally integrated.

Creating a passport that would benefit privileged groups will also pose a significant risk to vulnerable populations fleeing war or economic hardship. According to the UN High Commissioner for Refugees, including marginalised groups in vaccination programs is “key to ending the pandemic.” Yet while some refugee host states like Jordan and Lebanon are including refugees in their vaccine rollouts, several others are not. An estimated 9 out the 10 people living in the poorest states in the world may not receive the vaccine until 2022. If vaccine passports become a pre-requisite for travel, those people will be unable to seek asylum unless receiving nations put in place policies that would allow them to be vaccinated at the point of arrival.

Further reading

Interim position paper: considerations regarding proof of COVID-19 vaccination for international travellers by th WHO

The Passport by Sara Dehm

Challenges in ensuring global access to COVID-19 vaccines: production, affordability, allocation, and deployment


First published on: 15-04-2021 at 04:32:09 pm
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