A puzzling feature of so many proposed exit strategies from the COVID-19 pandemic is the enthusiasm for the use of electronic or paper documents to demonstrate the immunity status of their holder. This might come from prior infection (immunity certificate) or from vaccination (vaccine passport). While there has been a particular focus on these in the travel industry, governments have also shown interest in using them to regulate access to civil society. Only document holders would have the right to use certain facilities, like public buildings, sporting or entertainment venues or hospitality locations. Some suggest that this would be an incentive to encourage vaccine uptake without explicitly mandating this – although others might consider that to be a distinction without a difference. Nevertheless, it is widely claimed that such documents are the key to reopening civil society by increasing confidence in the lack of risk represented by exposure to other people, particular when in close proximity.
Important questions have been raised about the scientific basis for the assumed validity of these documents, given the continuing uncertainties about the nature and duration of COVID-10 immunity, whether from infection or vaccination. A test only gives information about a person’s status on the day of the test and proof of vaccination does not establish whether the vaccination has actually been effective. There are also numerous concerns about the ethics of this kind of certification, particularly its potential for social exclusion and discrimination, for the public display of normally confidential medical information, and for the tracking of citizens by states or corporations. Of course, there is a also a potential for fraud or forgery. In the UK, there have recently been two comprehensive reports on these issues from the Ada Lovelace Institute, which reviews ethical challenges in AI and related areas, and from the Royal Society, the most prestigious learned society in science. Both, however, tend to bow to the inevitability of certification and seek to mitigate it, rather than asking whether it actually has any value at all.
We may get some answers to that question by looking at the only working model of immunity status certificates that I have been able to identify – the US adult movie industry. If government ministers and airline CEOs examined the world of porn actors more closely, this might temper their eagerness to introduce these documents.
Immunity certification for adult movies developed in California during the late 1990s, after a serious outbreak of HIV among the performers. In an interview for The Lancet in 2004, Sharon Mitchell, the founder, describes how she recognized the need for such a scheme when following up an outbreak in 1996. This led to the establishment of an independent, non-profit clinic providing a range of health advice, testing and counselling services to people at high risk of sexually transmitted infections. The service included monthly testing for HIV, with the costs shared between performers and film producers. Mitchell’s clinic ran into legal and licensing difficulties, as well as experiencing a major data breach from a hacking attack on its medical records and closed in 2011.
It has been replaced by a national scheme, linked to the industry’s trade association. Since 2013 testing has been required every two weeks. Inclusion in the database is a prerequisite for working within the scope of the organized adult movie industry. Initially, I understand that there was a large element of self-policing. Performers would bring their most recent certificates to a shoot and exchange them before engaging in the required interactions. The online database now performs that function at the point of booking actors for a shoot.
Within the industry, the testing and certification regime has largely suppressed HIV since 1998, with just two documented outbreaks, in 2004 and 2009. The 2004 outbreak was a test failure, where the infection was too recent to be picked up. No details have been released of the 2009 outbreak. There have also been a number of sporadic cases, which have led to shutdowns for tracing and testing. The organized industry is relatively small and has good records of performer interactions that facilitate rapid contact tracing: in practice, the whole industry seems to shut down for a mass testing program because the networks are so interwoven. Apart from test failures, there are also said to have been problems with the fabrication or trading of clean certificates in order to remain in work but these are hard to verify. However, the scope for these will have been much reduced by the shift to online.
It should be stressed that the scheme, like the trade association itself, does not cover the whole adult movie industry. The growth of free sites, in particular, has challenged the, relatively, closed shop that used to operate in the twilight of Californian state law. Nevertheless, for those within its scope, it has provided a remarkable degree of protection for more than 20 years.
This scheme has been promoted, by the New York Times among others, as a model for COVID-19 testing, focusing on the role of a trusted third party provider of certificates and on the economic incentives to participate and gain access to employment. There is, though, a crucial difference between HIV and COVID-19. In the context of an adult movie, information about the other person’s HIV status, and the consequent risk of transmission, is relevant. There is no vaccine for HIV, so the only way for a performer to protect themselves is to know the immune status of the other performers with whom they are working. If there were an effective vaccine, particularly if it offered sterilizing immunity, this information would be irrelevant and disclosure would be unnecessary. HIV immunity certificates are proportionate to the risk for employment in the adult movie industry, where foregoing medical privacy is a reasonable condition of employment that makes the business possible at all.
In the context of COVID-19, however, the important thing to know is your own level of immunity because the vaccines are protecting you against virtually all the risks of serious illness or death. What risk remains is consistent with the risks from 30 or so other respiratory viruses that infect humans and which we have never thought it necessary to eliminate or control. If you sit next to someone with respiratory symptoms on a plane, your own vaccination or prior immunity is what matters, together with the ventilation environment. That flight may not be a pleasant experience – and it would be better to discourage people with such symptoms from travelling – but you are not exposed to any level of risk beyond that which you would have willingly accepted in 2019.
What, then, is the point of disclosing your status to the passenger in the next seat? Why do they need to know information about your medical status that we have traditionally considered to be private? The conventional answer is ‘reassurance’ – but what are they being reassured about? If the passenger in the next seat has also been vaccinated, then the risks are equally shared. If they have not, then the problem is theirs rather than yours. Sociologists are rightly skeptical about the way in which ‘reassurance’ can actually end up promoting fear and anxiety that are not proportionate to the perils involved.
Sociologists might also look more critically at the material interests involved. Are we seeing the beginnings of the kind of mission creep that has gone on with airport security since 9/11, a kind of theatre that has created a whole industry of suppliers and employees with interests in perpetuating and incrementally expanding their business. When did anyone last ask about the proportionality of the measures involved or about their contribution to increasing the acknowledged stresses of air travel? Who is going to make money out of vaccine passports or immunity certificates? This certainly seems to be a stronger driver than public benefit, once we have understood the nature of the infection risk and the relevance of the information that is being communicated.