Vaccine passports create a structural barrier to sustainable development, benefiting only the few at the expense of so many, say these authors
Where you are born can predict how freely you will be able to travel for opportunity, education, and leisure. Being a citizen of certain countries grants people access to nearly the entire globe, whereas others face challenges just to legally leave the borders of the country they live in, even during times of conflict.  The differential freedom of movement has been reinforced by inequitable trade policies, loan agreements, and increasingly due to the effects of climate change, reinforcing the economic and political dominance of Europe and North America and now China, while limiting the sustainable development of emerging economies. It was in this context where covid-19 rapidly emerged and led to further sustained limitations on local, domestic, and international movement across high income and low-and-middle income countries.
Encouragingly nearly 500 million doses of vaccines that are highly effective at decreasing the risks of severe covid-19, including hospitalization and attributable deaths, have already been administered globally. This has reignited the potential for the use of vaccine passports as a means of shaping future freedom of movement.
As nationalistic approaches rather than global coordination have generally defined the covid-19 response to date, it is not surprising that higher income countries (HIC) have hoarded vaccines through exclusive contracts and patent protections. This has limited exports to, production in, and ultimately population delivery across low- and middle-income countries (LMIC) [2-4]. The vast majority of vaccines have been administered in just a few countries including the United States, United Kingdom, certain European Union member states, and China. While North America and Europe have vaccinated 24% and 14% of their population respectively, only 0.6% of the population of Africa has been vaccinated so far.  Similar low levels of coverage are expected in LMICs in Latin America, Asia, and the Middle East and North Africa. While high income countries are projected to vaccinate most of their eligible citizens by the end of 2021, the same will only be achieved in LMICs over the next few years. 
In this context of inequitable vaccine availability, vaccine passports would limit the movement of millions of individuals from LMICs, reducing their opportunity to travel regionally or internationally for employment, education, and business opportunities. This would have a substantial impact on the economic and social development of these countries. Differential freedom of movement would likely result in unidirectional travel of people from HICs to LMICs reinforcing the economic reliance of LMICs on tourism rather than trade. At an individual level within LMIC, people from younger and higher socioeconomic demographics may seek vaccination for economic rather than exclusively health reasons. Given limited vaccine supply, “queue jumping” in LMICs may threaten, or at least delay, coverage in older and higher risk individuals sustaining risks for covid-19 related morbidity and mortality. In addition, there are an estimated 88 million more poorer people now globally, with the majority residing in South Asia and across Sub-Saharan Africa as a result of covid-19.  With decreasing domestic economic opportunities, increased economic migration may reinforce brain drain in LMICs as younger people leave to seek other opportunities. This may pose a pervasive challenge to sustainable development.
Extraction of human, natural, and financial resources from LMICs by HICs has long been the norm, often reinforcing dependence on aid when non-protectionist trade policies and facilitated industrialization would be better at supporting the sustainable development of emerging economies.  There have been times historically when the health and development situations facing LMICs were so grave that countries accepted the consequences of breaking medicines patents in order to save the lives of millions of people in LMICs. For example, increasing the provision of antiretroviral therapy for people living with HIV.  In our view, the urgency of covid-19 demands similar disregard for restrictive intellectual property laws that are preventing countries from saving lives. 
Vaccination provides an opportunity to resume in person education, which will facilitate the very scientific, technical, and public health exchanges that will improve future pandemic preparedness. Every vaccine that is hoarded by a HIC, above and beyond the needs of their citizens, is a vaccine that will not be available to a citizen in a LMIC in 2021. 
Better models do exist. For example, Senegal donated vaccines to the Gambia and Guinea-Bissau, facilitating vaccination of people at higher risk of covid across multiple countries, rather than vaccinating those at lower risk within individual countries.  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.  In this context, if vaccine passports are implemented, they have the potential to rapidly undo advances in sustainable development, by reinforcing rather than mitigating existing selective freedom of movement. 
Some people have suggested that vaccine passports are inevitable as they will facilitate the freedom of movement among citizens of high-income countries and people from higher socioeconomic populations from low- and middle-income countries. However, other approaches such as implementing testing for SARS-CoV-2 at departure or arrival, vaccination on arrival, or evidence of previous infection, collectively are complementary to vaccine passports for the coming years until sufficient global coverage of covid-19 vaccines has been achieved.
Ultimately, we need to facilitate the economic growth of emerging economies to increase the health, wellbeing, and security of all. Vaccine passports interfere with that future as they create a structural barrier to sustainable development, benefiting only the few at the expense of so many.
Stefan David Baral, Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore.
Jean Olivier Twahirwa Rwema, Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore.
Nancy Phaswana-Mafuya, Department of Environmental Health, Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa.
Competing interests: none declared.
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