How Vaccine Passports Will Worsen Inequities In Global Health

Even before Covid-19, high-income countries dominated all aspects of global health, including the ability to travel. Vaccine passports will make it harder for global health professionals from low/middle income countries to travel, attend meetings, get training, immigrate, or assume leadership roles

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Global health is neither global nor diverse. We knew that, even before Covid-19 came along. Folks in high-income countries (HIC) dominated all aspects of global health, including the ability to travel freely "to the field", to host & attend conferences in HICs, to consult, to serve on international panels, and to conduct research in any setting. In fact, most global health conferences are hosted in HICs and conference inequity’ is common in global health, with low and middle-income countries (LMICs) attendees under-represented at global health conferences.

With HICs beginning to implement Covid-19 vaccine passports, things could get much worse for LMIC folks in global health, and further privilege HIC folks who dominate global health. Let me explain why.

Even before Covid-19, reciprocity was a major challenge in global health. Every year, large numbers of HIC trainees and researchers visit LMICs to engage in global health missionsclinical tourism, research and consultancy work. Reciprocity would require HIC institutions, in return, to host LMIC trainees and experts. This rarely happens, as I have described in my 2-part article in Forbes.

One of the major reasons for lack of reciprocity is passport and visa privilege. Not everyone has a passport that can open doors, and nearly all HICs have huge visa restrictions and entry barriers. Even when HIC institutions invite LMIC experts and offer to pay for their visits, they struggle to get visas and often pay a lot for them. Visa denials can be traumatic. I know this from personal experience.

Now, with Covid-19, things are rapidly worsening, with widening income inequity, and vaccine inequities in terms of who is able to access Covid-19 shots. More than half a billion vaccine doses have been administered worldwide so far, and well over three-quarters of them have been used by the world’s richest countries. It might take many years for LMICs to reach a high level of vaccine coverage. The graphic below from NYT is quite striking.

This widespread vaccine inequity ('vaccine apartheid') automatically guarantees that HIC folks will be able to resume traveling for global health work, but LMIC folks will not. Most conferences and meetings in HICs might be out of bounds for LMIC experts, further sideling their expertise and their ability to assume leadership roles in global health. Most global health degrees are concentrated in HICs, and these programs will be harder to access for trainees in LMICs. Closure of borders and scale-back of immigration and refugee programs will further exacerbate the lack of diversity and inclusion that is widespread in global health. As airlines struggle with the economic collapse, flights will likely become more expensive and further penalize folks from LMICs. In essence, global health will become an even bigger one-way street than it already is!

In this powerful blog post, Nihan Albayrak-Aydemir counts the costs and missed research and career opportunities for passport-holders from the Global South. Every single cost and barrier she lists will likely get worse with Covid-19 vaccine passport and testing requirements for travel.

compared to those who have passport privileges, international scholars may lack opportunities for building international collaborations, giving invited talks or lectures abroad, attending international events or conferences, and serving on international disciplinary organisations to voice their perspective. This state of affairs has an impact on the long-term career trajectories of international academics as they encounter penalties for the lack of these experiences on their CV. Subsequently, it does not come as a surprise that Global South scholars may look less capable in comparison to their Western counterparts when it comes to job applications - Nihan Albayrak-Aydemir

As Maryn McKenna put it, "the arrival of vaccine passports could let affluent societies reach the far side of the pandemic while poor ones are still waiting to be protected from it, reinforcing the economic divides that the pandemic made so evident."

"The entrenched tiering globally that has always existed is being perpetuated, albeit unintentionally, as vaccine passports will effectively prioritize the mobility of people who are already privileged. The future requirement of digital documentation that demonstrates Covid-19 vaccine status may exacerbate inequality and leave many behind," wrote Joshua Cohen in this recent Forbes article.

His Scientific American article, Steven Thrasher writes "It is morally reprehensible (not to mention epidemiologically self-defeating) that countries can prevent vaccines from crossing their borders and want their own citizens to be able to cross those borders and travel to countries that are denied vaccines—and then use the threat of infection to keep the people of those unvaccinated countries inside them."

"Applying the commonly used precautionary principle means we need to assess the potential benefits and risks of vaccine passport policies in the context of the nationalistic vaccine hoarding observed to date," write Stefan Baral and colleagues in their BMJ Opinion.

If there is one silver lining, it is that the pandemic has allowed us to re-imagine global health education. As described in a recent article by 20 global health professors, global health teaching can be improved by using Covid-19 as a teachable moment to focus on equity and human rights as a central theme. The online format allows instructors to center voices from the Global South, Indigenous scholars, and individuals with lived experience of oppression and resilience. Remote teaching also helps us reach wider and diverse audiences, including groups that may not be enrolled in traditional degree programs. As global meetings, conferences and courses move online, it has definitely made it easier for our colleagues from LMICs to share their knowledge and expertise.

But any discussion on online technologies must consider the digital divide. Poor internet connectivity is still a big challenge for many LMICs, and might worsen inequities by favoring affluent participants in larger cities and middle-income countries. A sudden, dramatic shift to online learning as a result of the Covid-19 pandemic risks widening educational inequalities.

In summary, the power asymmetry and supremacy that pervades all aspects of global health will further privilege HIC folks, with the advent of vaccine passports, which exacerbates the inequities already seen in vaccine access. People and institutions who care about global health must work harder to advocate for vaccine equity. Even if vaccination records might become a practical necessity for travel in the near future, the real goal should be to do away with them by making sure everyone in the world is vaccinated or has access to them.

Madhukar Pai

Associate Director, McGill International TB Centre

I am a Professor and a Canada Research Chair in Epidemiology & Global Health at McGill University, Montreal. I serve as the Associate Director of the McGill International TB Centre. URL: http://www.paitbgroup.org/

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