From limited access to the COVID-19 vaccines in low-income countries to the debate around the very notion of a vaccine passport, Dr Augustine Asante, Director of the Global Health research program at the UNSW School of Population Health, writes about the equity implications of a COVID-19 vaccine passport that extend beyond health. 

The debate about COVID-19 vaccine passport is crystalising, it appears this will soon become a reality. For millions of people in rich countries, who have already been vaccinated or have access to a vaccine at any time of their choice, a vaccine passport sounds like a fair deal, but not for those in low-income countries with limited access to vaccines. 

For people in low-income countries, especially in sub-Saharan Africa, introducing a COVID-19 vaccine passport is a slap in the face and could come with a huge cost if rich nations use it to discriminate against citizens of low-income countries. 

Access to COVID-19 vaccines isn’t a level playing field 

Let’s start with the bare facts: around 4 billion doses of COVID-19 vaccines have been administered globally. Of these, low-income countries account for just 1%. In Europe and North America, around 47.0% of the population has received at least one dose of COVID vaccine. By contrast, less than 3% of the 1.3 billion people in Africa have received at least one dose. In Nigeria, a country with more than 200 million population, only about 1.2% has received at least one dose. This trend has been observed in other low-income settings, including the Pacific region. For example, in Papua New Guinea, only about 0.7% of the population has received at least one dose of a COVID-19 vaccine. 

The low rate of vaccination in poor countries is not by accident; it is indisputable that the COVID-19 vaccine playing field is by no means level, exacerbated by the unwillingness of rich countries to share access to the vaccines available. COVID-19 has exposed the selfish desire of nations to protect their interests despite the talk about global solidarity and ‘leaving no one behind’. 

The level of vaccine nationalism witnessed among the world’s richest nations over the last six or so months is stunning. With their vast purchasing power, rich countries have scooped nearly every COVID-19 vaccine dose on the market, some ordering far in excess of what is needed to vaccinate their populations, without regard to the needs of other countries. 

Australia is an exception but by accident. It did not join in the rush to grab every dose on the market, but not out of the abundance of good heart - the Federal government took a gamble on keeping the virus at bay by shutting down international travel and imposing a strict quarantine regime. Australia put all its eggs in one basket - the locally produced AstraZeneca basket - and didn’t put pressure on Pfizer and Moderna at the time other countries did. Nevertheless, Australia has still managed to secure reasonable doses of Pfizer in a very short period of time - a deal no low-income country can pull off. Despite having plenty of doses of AstraZeneca, Australians prefer Pfizer because of the rare blood clot associated with the AstraZeneca vaccine, increasing the pressure on the government to secure enough doses, compared to actual need. This is what privilege looks like in a rich country.

A vaccine passport could grow the divide between poor and rich 

With more than 50 countries currently implementing or planning to implement a COVID-19 vaccine passport, we cannot be blind to the equity implications of this policy.  

Domestically in Australia it can be viewed as a ‘carrot and stick’ policy - the carrot is the opening up of the country to those vaccinated, and the stick is to ‘whip’ the vaccine hesitant into taking the jab. A fair policy, perhaps, if you live in a country where a vaccine is available to everybody. 

What about the millions of people in countries with no or very limited access to a COVID vaccine? How fair is a vaccine passport policy that denies them entry into other countries based on their vaccination status?  

For low-income countries, a vaccine passport is also potentially problematic because it not just about whether someone is vaccinated or not; it’s also about which type of vaccine they received. And, countries implementing vaccine passports may not recognise a passport based on ‘unapproved’ vaccines. The majority of vaccines administered in low-income countries are either AstraZeneca manufactured by the Serum Institute of India, Sinovac from China, or Sputnik from Russia. Many western countries, including the EU, have not yet approved these vaccines despite approval by the World Health Organization.  For example, the EU has authorised four main vaccines for use in the European Union - Pfizer, Moderna, AstraZeneca and Johnson and Johnson but it is yet to approve the AstraZeneca made in India. The US has approved three vaccines - Pfizer, Moderna and Johnson & Johnson. Australia has approved only two vaccines - Pfizer and AstraZeneca. 

The EU is rolling out a digital COVID-19 certificate across its 27 member countries and four affiliated members - Switzerland, Norway, Iceland and Liechtenstein. The UK is working on its own National Health Service COVID-19 Pass, and hopes to have an agreement with the EU in recognising each other’s passports. The UK has received 5 million doses of AstraZeneca from India. The question remains whether the EU will accept these, and if so, would travellers from India or Africa vaccinated with the same brand of AstraZeneca be accepted in the EU?

True global solidarity needed to stop COVID-19 becoming a disease of poverty  

SARS-CoV-2 remains a terrible disease, and the current delta variant reminds us that no country is out of the woods yet. The world will be a much safer place if everyone is vaccinated regardless of where they live. Vaccine nationalism and imposition of vaccine passports to restrict entry to a country may offer only temporal protection. Countries need to stop holding onto the vaccines they don’t need or can’t use, before they expire,  and share with those desperately in need in the spirit of true global solidarity. 

This is our only passport out of this pandemic. Let’s not let COVID-19 become another disease of poverty. 
Dr Augustine Asante is the Director of Global Health at the UNSW School of Population Health in Sydney Australia. Read more about global health research in the School here.

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UNSW School of Population Health