COVID-19 immunity licensing in Africa: practical, socio-cultural, and ethical bottlenecks

Author: Amos Laar, Ph.D. Associate Professor of Public Health, School of Public Health, University of Ghana, Legon. E-mail: alaar@ug.edu.gh Twitter: @alaar
 
As of July 12 2020, the global tally of confirmed COVID-19 cases and deaths were respectively 12,552,765 and 561,617. The corresponding statistics for Africa were 578,734 and 12,996. As COVID-19 rages, debates regarding its modes of transmission, and the appropriate mix of countermeasures continue unabated. Emotive discourses relating to herd immunity and immunity-based licensing swirl on. Since March 2020, individuals, and state actors around the world have been mulling the use of an immunity licensing scheme. Referred to as “COVID-19 immunity passports”, the scheme is aimed at easing restrictions on movements but would also offer other opportunities.
 
In the African sub-region where response to the pandemic has been driven by a mix of science, politics, and faith, this commentary broadly examines the question of whether COVID-19 immunity passports will work. Specifically, I reflect on the socio-cultural, logistical, and ethical challenges that might arise from efforts to institute COVID-19 immunity certification/passports in Africa.
 
The WHO defines an immunity passport, or recovery certificate, as a document attesting that its bearer is immune to a contagious disease. The International Certificate of Vaccination birthed by WHO in 1969 is a related concept (e.g. yellow fever vaccination certificate). While immunity passports are not an entirely new concept, the potential for their misinterpretation, and misapplication is real. A recent Op-Ed suggested that healthy, young people deliberately infect themselves with SARS-CoV-2, as part of herd immunity-building campaign. Once infected, individuals who develop immunity (assuming they survive death), could be issued certificates to return to work and reboot the economy.
 
Currently, there is a handful but growing list of countries that have considered issuing immunity passports for those who have detectable antibodies to SARS-CoV-2. In May 2020, Chile started issuing "release certificates" to patients who have recovered from COVID-19, but clarify that "the documents will not yet certify immunity". Finland, Germany, the United Kingdom, the United States and South Africa are pondering over introducing the scheme.
 
The question of whether immunity licenses will work principally hinges on science. The science of COVID-19 immunity passports is current equivocal; it’s unclear whether infection with SARS-CoV-2 confers immunity to reinfection and, if it does, whether or not it is sterile immunity. The WHO indicated that there was not enough evidence about the effectiveness of antibody-mediated immunity to guarantee the accuracy of an immunity passport. The main motivations for immunity passports is resuscitation of the economy. However, knowing what we do about COVID-19, the notion that immunity-wielding persons can reboot the economy is not only wishful thinking, it’s deeply troubling. As the President of Ghana admonishes, “we know how to bring the economy back to life. What we do not know is how to bring people back to life”. Indeed, giving the low COVID-19 testing in Africa, there would be too few immunity-certified survivors to keep the economy alive.
 
Besides science, there are practical/logistical challenges to COVID-19 immunity licensing. Professor Samia Hurst of the University of Geneva’s Medical School, notes that even “if sufficient scientific certainty of immunity accrue, guaranteeing sufficiently equal rights for all would necessitate substantial and rapid reorganization of society so that the nonimmune individuals can exercise their rights and make meaningful choices”. Such reorganization would negate much of the usefulness of immunity passports. Natalie Kofler and Françoise Baylis argue that the volume of testing needed to fully implement immunity licensing would be mindboggling. For example, Ghana, with a population of about 30 million, would require a minimum of 60 million serological tests to validate everyone’s COVID-19 immune status–assuming two tests per person. Repeat testing, (at least once per year), would be necessary to confirm immunity. Currently, shortage of COVID-19 test kits has been a cardinal characteristic of Africa’s response.
 
Ethically, even if the scheme were feasible, it could create a dangerous incentive for some to acquire the virus to qualify for the passport. If immunity certificates provide benefits, there would be an unhealthy scramble for it. As with much sought-after essential commodities, one would expect black marketeering of COVID-19 immunity passports. Of note, this would not be unique to Africa. Henry Greely suggests some people may use another’s immunity certificate, unless it had a driver’s license-like photograph. Even in that case, it’s possible for people to go around this, unless it came with biometric facial recognition or retina-linked identification. Stories of state officials illegally granting travel passports in exchange for bribes abound. Health officials have been accused of bribery in yellow fever checks at border posts.
 
Even if we had genuine immunity certificates and ethical officials, implementation in Africa will still be challenging. For instance, would governments require that only people with immunity certificates be allowed to work, or access congregate settings, e.g., crowded local markets, restaurants, places of worship, or public transportation? Given the lack of resources/capacity, both formal and informal spaces would be sub-optimally regulated or monitored. Still, even if this were to be feasible, many people will resent this, especially if their colleagues/friends regain their freedom, and return to work because they had an immunity passport. Often acknowledged as communitarian, it would be un-African/anti-communitarian to discriminate based on who carries COVID-19 antibodies. We could see law courts back resistance groups as was witnessed during the lockdowns in some African countries.
 
Finally, should there be consensus on the legality of COVID-19 immunity licensing, its implementation could be counterproductive or unfair. It would be a regrettable public health paradox to have those who faithfully followed social distancing and other COVID-19 prevention directives (and were not infected) ultimately unfairly disadvantaged. Certifying the immunoprivileged (recovered individuals) as fit to work would not only stigmatize the uninfected (immunodeprived), the immunodeprived could be classified as disabled, whose needs would need to be accommodated, experts argue. This raises concerns of reverse stigma where the uninfected are ultimately stigmatized.
 
Therefore, in theory, COVID-19 immunity-based licensing may be a plausible countermeasure, but the logistical, socio-cultural, and ethical bottlenecks associated with its implementation, especially in Africa, seem to dwarf its benefits.

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