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At the turn of the 20th century, the United States was in the grip of a full-blown smallpox epidemic. During the five-year outbreak from 1899 to 1904, government health officials confirmed 164,283 cases of smallpox, but the real numbers may have been five times as high.
To slow the spread of the highly infectious and often deadly virus, there was a nationwide push for smallpox vaccination. In cities and states with the worst outbreaks, vaccination was compulsory and official certificates of vaccination were required to go to work, attend public school, ride trains or even go to the theater.
The mandatory vaccination orders angered many Americans who formed anti-vaccination leagues to defend their personal liberties. In an attempt to dodge public health officials, who went door-to-door (often with a police escort) to enforce vaccination laws, some anti-vaccination activists would forge certificates of vaccination. Unable to tell if certificates were legitimate, health officials fell back on physical evidence: they demanded to see a vaccination scar.
READ MORE: When the Supreme Court Ruled a Vaccine Could Be Mandatory
Smallpox Vaccination Was a Brutal Business
Following a technique first developed by Edward Jenner in the late 18th century, smallpox vaccination in 1900 meant scoring the skin of the upper arm with a lancet or knife, and then dabbing the wound with live virus. Vaccine makers in 1900 still sourced their virus from oozing cowpox sores on the underside of calves.
“The vaccine recipient would start to feel quite sick, usually with a fever and a very sore arm,” says Michael Willrich, a history professor at Brandeis University and author of Pox: An American History. “The vaccine site would become more and more irritated, a scab would form, fall off, and what was left behind was a small scar roughly the size of a nickel. And that’s how you’d know that the vaccination took.”
READ MORE: How an Enslaved African Man Helped Save Generations from Smallpox
Fake and Forged Vaccine Certificates
Partly because the vaccination process was so brutal, and partly because anti-vaccination crusaders exaggerated the risk of contracting tetanus or syphilis through the vaccine, there were plenty of people who tried to avoid vaccination by any means necessary. The most common tactic was to buy a fake vaccination certificate.
Even as late as 1904, an article in The New York Times headlined “Vaccination Certificate Frauds” reports on “an extensive traffic in worthless certificates of sufficient vaccination by east side physicians” perpetrating a “petty swindle on the poor, ignorant and credulous.”
With all public schools requiring proof of vaccination, anti-vaccination leagues circulated names of doctors who would sign a piece of paper saying that a child was medically “unfit” for vaccination. If parents didn’t want to pay the doctor, they forged the medical certificate themselves.
The Scar as ‘Passport’
In the overcrowded tenement districts of cities like New York and Boston where smallpox spread with deadly speed, health officials enlisted policemen to help enforce vaccination orders, sometimes physically restraining uncooperative citizens. Frustrated with the widespread resistance to vaccination, these vaccine squads began to ignore certificates altogether and go right to the source.
“Because certificates could be so easily forged, they’d insist on seeing the vaccine scar,” says Willrich. “Vaccine scars readily served as a physical form of certification.”
In 1901, respected physician Dr. James Hyde of the Rush Medical College in Chicago wrote an editorial urging public health officials to do everything in their power to eradicate smallpox and proposed using the vaccination scar itself as the sole entry ticket or “passport” to civic life in America.
“Vaccination should be the seal on the passport of entrance to the public schools, to the voters’ booth, to the box of the juryman, and to every position of duty, privilege, profit or honor in the gift of either the State or the Nation,” wrote Hyde.
READ MORE: How Crude Smallpox Inoculations Help George Washington Win the Revolutionary War
The End of Smallpox
In schools, factories, and halls of government, as well as aboard immigrant ships arriving at U.S. ports of entry, those who couldn’t produce a “fresh” vaccine scar—signaling inoculation within the past five years—would be vaccinated on the spot.
In 1903, the state of Maine issued a decree that “no person be allowed to enter the employ of, or work in, a lumber camp who can not show a good vaccination scar.” In that same year, industrialist Henry Clay Frick ordered all employees at his Pittsburgh-area steelworks and their families to show a scar or be vaccinated.
“This order would have affected 300,000 people,” says Willrich. “That’s pretty significant coming from one enterprise.”
As late as 1921, when Kansas City suffered a smallpox outbreak, a local newspaper reported that “‘Show a scar’ has been officially adopted as the passwords to lodges and other meetings.”
Anti-vaccination sentiments never went away entirely, though, and some Americans even took to forging their vaccination scars. They did it by painfully exposing a patch of skin to nitric acid to produce the same nickel-sized scab and scar.
READ MORE: Full Pandemics Coverage
The Vaccine Passport Debate Actually Began In 1897 Over A Plague Vaccine
This isn't the first time the world has been engaged in a conversation about "vaccine passports." And there even is a version of a passport currently in use – the World Health Organization-approved yellow card, which since 1969 has been a document for travelers to certain countries to show proof of vaccination for yellow fever and other shots. Without which they can't visit those countries.
But first, let's flash back to the late 19th century – 1897 to be exact. A scientist from Odessa, Russia, Waldemar Haffkine, developed a vaccine for plague. He was hailed as the "Jewish Jenner" (a shout-out to Edward Jenner, inventor of the smallpox vaccine in 1796).
Once Haffkine's vaccine was put into use in British India, discussions started about asking for proof of vaccination in certain circumstances, according to Sanjoy Bhattacharya, a professor of history at the University of York in the U.K. and director of the WHO Collaborating Center for Global Heath Histories.
One area of concern: Hindu and Muslim pilgrimage sites, which, due to population density, were considered spaces where outbreaks of plague could get out of control.
A good example, says Bhattacharya, was the annual pilgrimage to the town of Pandharpur in the colonial Bombay province. Authorities decided to make proof of vaccination compulsory for pilgrims but only after detailed, annual negotiations between government, the railway companies, the hospitality industry, pilgrims' representative and temple authorities.
Bhattacharya stresses that no world body can order such a requirement. It can only come about as the end result of long deliberations among relevant parties, he says.
Similar discussions were held about smallpox at about the same time at the plague vaccine was developed. "When there were outbreaks in South Asia people from there were not allowed to board ships, for instance, to Aden or Great Britain, or Mecca for the Hajj, without government-issued smallpox vaccination certificates," Bhattacharya says. At that time, vaccinations were given at government centers, which handed out a certificate to those who got the vaccine.
"These matters were considered even more urgent in the second half of the 20th century after the introduction of air travel," says Bhattacharya. In that era, someone infected with smallpox could quickly and easily reach Europe while infected and cause local outbreaks of this much-feared disease. So, smallpox vaccination certification checks were enforced before travel, "with forcible isolation at airports of any passengers considered to have dubious documentation."
Vaccine certification checks came under the International Sanitary Regulations adopted in 1951 by WHO member states (and replaced by and renamed the International Health Regulations in 1969.
Currently, yellow fever is the only disease specified in the International Health Regulations for which countries may require proof of vaccination as a condition of entry. However, WHO can recommend, based on outbreaks, that countries ask for other vaccines. For example, there is a current recommendation that Pakistan and Afghanistan ask travelers to be vaccinated with a single adult dose of polio vaccine if they have not been vaccinated against polio since childhood.
But any type of vaccine proof is not a blanket rule all must follow, says Bhattacharya. "All recommendations from WHO are necessarily advisory in nature and open to interpretation across countries, during implementation."
So that's one of several concerns about any effort to create a global COVID-19 passport.
"No entity has a mandate to create universal certification, and the situation is tricky because it could be at least a couple of years before everyone in the world is vaccinated," says Jen Kates, senior vice president and director of Global Health & HIV Policy at the Kaiser Family Foundation in Washington, D.C. "A certification now could exacerbate inequities for such things as employment in other countries for people not yet vaccinated," says Kates.
In February, WHO published a position paper on the scientific, ethical, legal and technological issues that may arise when requiring international travelers provide proof of a COVID-19 vaccination. The paper recommended against requirements of proof. WHO reiterated that position to NPR this week again for several reasons. To quote their email:
"At the present time, it is WHO's position that national authorities and travel operators should not introduce requirements of proof of COVID-19 vaccination for international travel as a condition for departure or entry for a number of reasons.
"The efficacy of vaccines in preventing transmission is not yet clear, and the current limited global vaccine supply. While many vaccines have been shown to protect against disease, studies are ongoing to determine if they also stop the transmission of the virus: that a person who is vaccinated cannot carry the virus and give it to others.
"WHO recommends that people who are vaccinated should continue to comply with other risk-reduction measures when traveling."
That's not WHO's final word on vaccine certificates. The agency says, "our recommendations will evolve as supply expands and as evidence about existing and new COVID-19 vaccines is compiled."
But WHO may not have the luxury of time. "This train [of vaccine certification] has already left the station because people want to know that the people around them are immunized," says Dr. Chris Beyrer, the Desmond M. Tutu Professor of Public Health and Human Rights at the Johns Hopkins Bloomberg School of Public Health. The European Union, for example has proposed what it's calling a digital green pass that could allow travel for people who've been vaccinated, recovered from COVID-19 or show a negative test for the virus.
Like Kates, Beyrer says he understands WHO's position because there are still countries "who have yet to administer a single dose." And in this have- and have-not situation, people without certificates likely wouldn't be able to go to school or look for work in other countries.
Meanwhile, the goal of vaccine equity across the globe isn't just for economic or educational reasons, Beyrer points out. "Leave swaths of people unimmunized, and we run the risk of more of these variants of concern and an undermining of the current generation of vaccines."
As for what the certification will look like, Beyrer is sentimental about his own yellow card from his work in the 1990s in polio eradication and measles control in Caribbean countries. But he predicts the era of paper proof is coming to an end. He thinks any certificate for COVID-19 will be a smart app linked to a central database or electronic health records.
"Of course," says Beyrer, "that raises the issue of the digital divide in many countries."
In 1716 Lady Mary Wortley Montagu arrived in Turkey with her husband Lord Montagu, the new British ambassador to Turkey. Two years earlier, she had survived a bout with smallpox but bore the scars left by the disease. Lady Montagu mastered the local language and befriended Turkish women, through whom she made an extraordinary discovery: Her new friends would deliberately infect themselves and their children with pus from smallpox sufferers. They then suffered a mild bout of the disease, after which they were left immune to its deadly effects.
Smallpox had been infecting people in Asia, Africa, and Europe for centuries, but Australia, the Americas, and the Pacific Islands had been isolated from the disease. As European explorers came into contact with these populations in the 1400s and 1500s, they exposed them to smallpox and devastated them. For instance, the Aztec population numbered roughly 26 million in the early 1500s: By 1620, it was 1.6 million. These epidemics allowed European colonizers to seize new lands and conquer the surviving people.
Centuries later, smallpox became a weapon that colonists actively used it against native populations. In 1763 during Pontiac's War, the British gave contaminated blankets to Native Americans in the hopes of causing an outbreak, one of the earliest examples of biological warfare. An epidemic did break out in the Ohio Valley that lasted through 1764, although it is uncertain if it was directly caused by the infected linens or transmitted another way.
Lady Montagu was deeply impressed. She was a highly independent woman who had already taught herself Greek, Latin, and French and who had married against the wishes of her parents. Without hesitation Lady Montagu inoculated her own children, declaring: “I am patriot enough to take pains to bring this useful invention into fashion in England.”
Such methods were, in fact, already used in Europe, but Lady Montagu’s great achievement was to publicize the technique—which became known as variolation—and to energetically defend it against the entrenched hostility of some doctors and even priests. Thanks to her campaign, a number of high-profile personalities inoculated themselves using the Turkish method, among them the kings of Denmark and Sweden and the Russian empress Catherine the Great.
Variolation had a serious shortcoming: between one and three percent of those inoculated fell ill and died. This mortality rate explains why the procedure never became a fully established practice. Lady Montagu, who had done so much to fight smallpox, died of cancer in 1762.
The first documented anti-vaccine group called the National Anti-Vaccination League appeared in 1866 after Britain's government tried to mandate smallpox vaccinations for its constituents.
All sorts of messaging emerged from the group, including religious stances arguing that getting sick is part of God's plan, and libertarian points of view that proclaimed the government can't tell individuals what to do.
Later, a similar anti-vaccination league appeared in Boston that distributed misinformation about the vaccine by mail and solicited donations, Najera said.
Black History Month: Onesimus Spreads Wisdom That Saves Lives of Bostonians During a Smallpox Epidemic
In the early 1700s, about a century before Edward Jenner conceived the idea of a smallpox vaccine based on the cowpox virus, smallpox was going through New England and other American Colonies. In Massachusetts, colonists there saw smallpox arrive with cargo ships to Boston over and over again. There was not much the authorities could do beyond imposing quarantines and treating the sick.
This changed in 1721 thanks to the wisdom passed on from Onesimus, an African slave sold to Cotton Mather, an influential minister in Boston. (You might remember Mather from learning about the Salem Witch Trials.) Mather had bought Onesimus in 1706 and came to converse with him and learn about Onesimus' past. When Mather asked Onesimus if he had ever had smallpox back in Africa, Onesimus described the practice of variolation to prevent smallpox epidemics.
Variolation consisted of first taking infectious material (like pus) from the blisters of smallpox patients. A healthy person then receives the material through a cut in the skin in a controlled manner and under the supervision of a physician. This was done so that the smallpox symptoms would be milder but still confer some sort of immunity in the future. Of course, the procedure was not without risk. People still developed severe symptoms and even died from smallpox via variolation, but those who died were in much smaller proportion to those who acquired it naturally from another person. (See how Benjamin Franklin reasoned it through and put his observations in a pamphlet: https://www.historyofvaccines.org/content/blog/epidemiologist-benjamin-franklin).
After hearing Onesimus' story, Cotton Mather began to research the practice of variolation. He found that it was practiced in many parts of the world, not just Africa. Or, as he recorded in his diary, "the new Method used by the Africans and Asiaticks, to prevent and abate the Dangers of the Small-Pox, and infallibly to save the Lives of those that have it wisely managed upon them." Places like China and Turkey had their own versions of variolation based on the same principle of exposing a person under controlled circumstances rather allowing them to contract it naturally. The practice was so effective in conferring immunity that African slaves sold in Massachusetts at the time were deemed to be more valuable if they bore the scar of variolation.
This research and correspondence with medical experts at the time encouraged Cotton Mather to push for variolation in the colonies. He burned some of his political and social capital in advocating for variolation before the next epidemic hit Boston. Needless to say, his proposal met with resistance. Anti-variolation sentiment was strong in its response to the idea:
“As word spread of the new medicine, the people of Boston were terrified and angry. According to Mather, they “raised an horrid Clamour.” Their rage came from many sources fear that inoculation might spread smallpox further knowledge that the bubonic plague was on the rise in France and a righteous fury that it was immoral to tamper with God’s judgment in this way. There was a racial tone to their response as well, as they rebelled against an idea that was not only foreign, but African (one critic, an eminent doctor, attacked Mather for his “Negroish” thinking). Some of Mather’s opponents compared inoculation to what we would now call terrorism—as if “a man should willfully throw a Bomb into a Town.” Indeed, one local terrorist did exactly that, throwing a bomb through Mather’s window, with a note that read, “COTTON MATHER, You Dog, Dam You I’l inoculate you with this, with a Pox to you.”
In 1721, half of Boston's residents were infected with smallpox, about 11,000 people. Zabdiel Boylston, a physician who believed Cotton Mather and Onesimus on variolation, inoculated his own son and the slaves in his possession. The result was that one in forty people inoculated by Boylston died from smallpox. In those who acquired it naturally, one in seven died. A risk ratio of 5.7, meaning that people who acquired the disease naturally were almost six times more likely to die than those who acquired it by variolation.
At the end of the epidemic, 14 percent of the population of Boston was dead. Based on this experiment with variolation, the practice became more accepted in the colonies facing smallpox epidemics. By 1796, the vaccine based on cowpox would be developed by Edward Jenner. By the mid-1800s, variolation was discontinued in favor of immunization with cowpox as immunization was safer and more effective than variolation.
Onesimus would go on to partially purchase his freedom but still remaining in the service of Cotton Mather. His contribution to the understanding of smallpox and its prevention lives on today.
Everything you need to know about smallpox vaccine scars
Smallpox is a viral infection that causes a fever and severe skin rash.
The early 20th century saw several smallpox epidemics, and the infection was fatal for about 3 out of 10 affected people. The infection left many people who survived smallpox with permanent scarring, frequently on their faces.
Smallpox is an infection of the variola virus. Scientists developed a smallpox vaccine using a live variation of a virus called vaccinia. Vaccinia does not cause smallpox, but it is very similar to the variola virus that does.
When the human body encounters vaccinia, it builds up antibodies to fight off the variola virus.
The vaccination was so effective that in the early 1950s, scientists declared that smallpox had been eradicated. In 1972 , doctors discontinued smallpox vaccinations in the United States, except among people at risk of exposure to the infection — in a lab, for example.
The smallpox vaccine left behind a scar at the injection site. Keep reading for more information about the smallpox vaccine scar.
Share on Pinterest The smallpox vaccine leaves behind a distinctive mark.
A smallpox vaccine scar is a distinctive mark that smallpox vaccination leaves behind.
The scar may be round or oblong, and it may appear deeper than the surrounding skin. Usually, the scar is smaller than the diameter of a pencil eraser, though it can be larger.
In some people, smallpox vaccination scars are itchy or uncomfortable. This is part of the body’s normal response to scarring.
A scar forms in response to an injury, such as the puncture involved in smallpox vaccination. As the body repairs the damage, it forms scar tissue.
In most people, this scar tissue is small. However, some people experience an inflammatory response to the injection of the vaccine, which can lead to a larger, raised scar.
A smallpox vaccination scar occurs because the vaccination causes an injury at the injection site.
Other vaccinations typically involve injecting fluid with thin needles. However, smallpox vaccination requires a different method of injection.
When administering this type of vaccination, a healthcare provider dips a two pronged — or bifurcated — needle into the vaccine fluid, then jabs the needle forcefully into the person’s arm.
The body’s immune system reacts to the live virus in the vaccination by creating a defense that pushes the virus out. It is this reaction that leads to the scarring.
As the body fights the infection, a scab begins to form. The scab may ooze and feel itchy and tight. This is a normal reaction to scabbing.
As the injury at the injection site heals, the scab falls off and leaves behind an area of skin that looks like a pockmark.
Typically, a person received the smallpox vaccination in the upper part of their left arm, though doctors sometimes administered these vaccines in other areas, such as the buttocks.
While most people received smallpox vaccinations without any problems, complications sometimes occurred.
However, no one has been infected with smallpox from the vaccine because the vaccine contains a different virus.
After receiving this vaccine, a person may experience mild, flu-like symptoms, including:
Unlike some other vaccines, the smallpox vaccine contains a live virus. This means that people who receive the vaccine need to take extra care of their injection sites to avoid spreading the virus.
In rare cases, people experience more serious complications, such as:
- allergic reactions vaccinatum, an extensive skin infection that can develop in people who already have eczema
- a large sore that does not heal, which is more common in people with weakened immune systems
- postvaccinal encephalitis, which involves inflammation in the brain
A person can try various methods of removing or reducing the appearance of a smallpox scar, including:
- using sunscreen, as sun exposure can make scars more noticeable
- using skin softening ointments and creams
- asking a doctor about dermabrasion or skin grafting
A widespread vaccine campaign in the middle of the 20th century eradicated smallpox. As a result, smallpox vaccination is no longer a common practice in the U.S.
Typically, only people at risk of exposure, such as those who work with the virus in labs, receive smallpox vaccination.
People who have received this vaccine may experience some itchiness at the site of injection, as well as a scab and, eventually, a scar. These are normal features of the healing process.
The History Of Vaccine Passports In The U.S. And What's New
Next, we report on the backstory of vaccine passports. The idea here is that you'd be required to show proof of immunization against COVID-19. The airline industry and universities and retailers are all considering ways to do that. But the effort has prompted accusations that some people would lose some of their freedom or medical privacy. The idea of a vaccine passport, though, is not new. Here's NPR's Yuki Noguchi.
YUKI NOGUCHI, BYLINE: The smallpox vaccine was first developed in 1770, but historian Jordan Taylor says small outbreaks continued to crop up across the U.S. for nearly two centuries after that. Factory workers, for example, infected each other by the dozen, developing sores that quickly spread over their bodies.
JORDAN TAYLOR: Pustules usually around your arms or your lymph nodes. And it's quite repellent, actually. It's extremely painful, very contagious. It's a gnarly disease.
NOGUCHI: And one that killed about a third of those infected. The country's first vaccine passport system was developed in response in the 1800s. Taylor, who teaches at Smith College, says local health officials or state governments started requiring proof of immunity when traveling or applying for a job. Train conductors and employers asked people to show either a scar left by a vaccine, a face pockmarked by smallpox or a doctor's certificate showing they'd been inoculated. Schools began requiring proof of smallpox vaccination to enroll, a practice that continues to today for myriad other diseases. Such measures proved highly effective at controlling infection. It enabled the economy to keep moving. And for the most part, the public accepted it as part of the public health bargain.
TAYLOR: For people in the 19th and 20th centuries, it really wasn't a question. It was obviously the case that this sort of vaccine passport system was preferable.
NOGUCHI: That's not to say there weren't vaccine skeptics. Taylor says a black market developed a century ago for forged certificates for those avoiding vaccination.
TAYLOR: Or to even create and sell fake scars made of plaster and things like that so that they can bypass and get around these restrictions.
NOGUCHI: But for the most part, he says, vaccine passport systems were seen as a ticket to greater freedom.
TAYLOR: There was a different understanding of what it meant to be free.
NOGUCHI: A century ago, the public measured freedom in terms of their ability to gather publicly or participate in community activity.
TAYLOR: There's actually, as far as I can see, relatively little talk about violation of their liberties or their rights, the sorts of discourse that we're seeing now in response to the proposals for vaccine passports.
NOGUCHI: Today, those opposed to vaccine passports also express concern for the security and privacy of medical information. James Colgrove, a public health professor at Columbia, says that wasn't an issue 100 years ago because both smallpox and the vaccine left physical scars.
JAMES COLGROVE: It was much easier to check immunity back then. You just asked people to roll up their sleeves. Privacy was not really so much an issue.
NOGUCHI: Today, by contrast, people worry that a digital vaccine passport system could link to other databases that in turn could compromise other private information. And, says Colgrove, compared to a century ago, mistrust of government today runs very high.
COLGROVE: We're at one of those times when anti-government sentiment is particularly vehement. And so you throw that into the mix along with the mass spread of disinformation over the Internet, and it's a very toxic combination.
NOGUCHI: What's important, he says, is to not allow politics to derail public health measures like vaccine passports, which helped eradicate smallpox in the U.S. by 1950.
(SOUNDBITE OF NORTHCAPE'S "CAPILLARY ACTION") Transcript provided by NPR, Copyright NPR.
Vaccine Passports and the scars that won't heal
The polarising debates on vaccine passports have taken centre stage in the global discourse on the pandemic with some hailing them as a golden ticket to normality and others seeing them as another way in which governmental coercion is legitimised under the smokescreen of safety.
The idea is incredibly straightforward — a digital document will verify whether a person has been vaccinated or recently tested negative for Covid19. Presenting this would permit people to travel and enjoy activities that are still largely prohibited under each nation’s respective lockdown measures.
Though the B iden administration has stated that there will be no mandate for such documentation many nations are now keen to implement their use as global vaccination programs continue to fight the ongoing pandemic, despite the WHO stating that it does not support the idea. In the UK for example, 63% strongly support the introduction of a vaccine passport to allow overseas travel according to Kantar Research Group.
However, though many view them as a way of travelling freely vaccine passports are still a valid cause for concern. After all, the myth of the pandemic affecting everyone equally, that somehow, according to Boris Johnson “we are all in his together”, has been completely dispelled.
One only needs to glance at the increased share values of companies such as Zoom and Amazon and compare that to the mass unemployment of jobs in hospitality, art and leisure to see that those with power and money have gained considerably from many people’s turmoil.
Huge disparities in death and infections rates in minority groups have also widened deeply over the past year. This has most notably been seen in the United States where it has been reported that Black Americans have received the vaccine at half the rate of white Americans according to Yara M.Asi details in The Conversation.
Additionally, there is a genuine cause for concern about the implementation of vaccine passports as means of normalising coercive and overly intrusive government powers. Ultimately where one stands on the issue depends entirely on their subjective understanding of liberty and whether they believe their government’s intentions are malevolent or benevolent.
Maria Alvarez in The Guardian recalls how John Stuart Mill once argued that in a “civilised community”, coercive governmental interference was justified if it was explicitly used to prevent harm to others and to oneself. Though the data on the success of lockdowns is far from conclusive such a measure would fit under this definition. However, one must draw the line somewhere as safety is all too often used as a tool to encourage people to relinquish their freedoms — the Patriot Act is only 20 years old.
The debates on vaccine passports also must not be conducted in a historical vacuum. After all, as Jordan E.Taylor details in Time Magazine, the implementation of a vaccine passport would not be American history’s first as he recounts Americans’ long campaign against smallpox.
The smallpox vaccine was introduced in the 18th century and was said to leave visible scarring after being administered. Even then, the anti-vaxxers of the day used this to state that such markings were the clearest signs of tyrannical measures forced upon people. Border officials at the end of the 19th century often required passengers to provide evidence that they had been vaccinated from smallpox upon entry to the United States.
Taylor points out the fundamental fact that Covid 19 vaccinations make it almost impossible to determine who is immune and who remains at risk as no such scarring is present and the use of vaccine passports could provide a scar-free solution to ensuring public safety.
From Smallpox to Covid-19: The history of vaccine passports and how it impacts international relations
As the global administration of Covid-19 vaccines escalate, several countries, non-governmental organisations and private corporations have announced plans to introduce a system of Covid immunisation certificates to facilitate travel.
Called vaccine passports, these documents will essentially serve as digital or paper-based certificates enabling anyone vaccinated against Covid to move across international borders.
They are designed to provide a private and secure way of checking who has been vaccinated, allowing them to present proof of the same.
The verification process typically involves two steps. First, a vaccination site provides a digital record or certificate with details of a person’s vaccination. That person would then either scan the certificate or manually upload a verification number onto an app or a website. They could then present that app or code to airlines, restaurants or other establishments to prove their vaccination status.
Currently vaccine passports gaining traction include the European Union’s Digital Green Certificate, New York’s state-backed platform Excelsior Pass, Common Pass, an initiative from the non-profit Commons Project Foundation, and IBM’s yet-to-be-released blockchain enabled certificate. Along with several vaccine passports introduced by individual airlines, the international Air Travel Association (IATA) has also called on the 290 airlines that it represents to sign up for its IATA Travel Pass. Similar to choosing between several credit cards for payments, customers will be able to shop around for vaccine passes, using different ones to avail of various services.
Countries, trading blocs and airlines have stipulated their own parameters for these certificates, and a few will continue to require them in conjunction with a negative Covid-PCR test. However, despite those variances, the common consensus is that people in possession of a vaccine passport will enjoy greater access to freedom of movement across international borders than their non-vaccinated counterparts.
Earlier this year, an article published by the World Health Organisation (WHO) raised concerns surrounding the operational, ethical and diplomatic consequences of allowing certain individuals to avail of privileges that others face hurdles to access. Each country has its own definition of individual liberties and how they apply the use of these passports internally will vary in accordance with their laws and constitutions. As per a March 2021 research paper in the Lancet, failure to create a uniform system of vaccine passports to regulate cross-border movement could escalate diplomatic conflicts and widen the gulf between richer and poorer nations.
History of immunisation passports
The concept of requiring proof of immunisation to occupy certain spaces dates back to Edward Jenner’s development of the first known vaccine in 1796. Designed to inoculate people against smallpox, confirmation of having taken this vaccine was a prerequisite for travellers at the time, mostly pilgrims, entering towns such as Pandharpur in British India or going to Mecca for the Hajj. Continuing into the 19th century, this policy was widely implemented across the globe with the El Paso newspaper reporting that travellers entering the United States had to show either a vaccination certificate, a scar on the arm or a “pitted face” indicating that they had survived smallpox.
In an interview given to NPR, Sanjoy Bhattacharya, professor of history at the University of York, says the need to provide proof of vaccination intensified after the introduction of air travel in the 20th century. Till then, people infected with smallpox could easily travel to other countries and risk outbreaks in local populations. Thus, vaccination certification checks were enforced before travel “with forcible isolation at airports of any passengers considered to have dubious documentation.”
Vaccine certification checks are even codified under international law with the first protocols defined under the International Sanitary Regulations Act, adopted by WHO member countries in 1951. Since renamed the International Health Regulations (IHR) in 1969, this Act allowed member states to demand proof of vaccination as a condition of entry. While now yellow fever is the only disease specified in the IHR, the WHO has recommended that certain high-risk countries require travellers to provide vaccination certificates for diseases from which their population has not been sufficiently inoculated. For example, visitors to Pakistan and Afghanistan are recommended by the WHO to take adult doses of the polio vaccine before travelling due to the prevalence of the disease in those regions.
As of now, the WHO has maintained a stance against Covid vaccine passports citing the risk they pose in perpetuating global inequality, a lack of evidence on vaccine efficacy in terms of herd immunity and the substantial operational challenges that such a system would present.
Operational and Ethical Considerations
A number of scientific unknowns remain concerning for governments when evaluating the impact of Covid vaccines in stopping the spread of the disease. These include their efficacy in limiting transmission, especially for variants of the virus, the duration of protection offered by vaccination, the distinctions between different vaccines, whether or not booster doses are required, whether vaccines protect against asymptomatic infections and whether people who have antibodies should be exempt from vaccination. Simply put, no one knows how or if vaccines will prevent transmission and therefore organisations like the WHO and other human rights groups warn against the introduction of vaccine passports, lest people view them as an excuse for complacency. These uncertainties have the potential to cause serious diplomatic incidents especially if tourists from certain countries cause wide-spread outbreaks in visiting regions after being vaccinated via their national rollout programmes.
Furthermore, with several competing vaccination passes, the possibility of fraud is high. Researchers at cyber-security company Check Point have monitored hacking forums and other marketplaces since January 2021, when vaccine adverts first appeared. Everything from a vaccination certificate to a negative PCR test to a dose of the vaccine can be bought illegally online (it is unclear whether the doses offered are effective or not.)
Without a central database of vaccination records, a system that would be highly concerning to data-privacy advocates and national security hawks, not to mention a logistically herculean task, forgeries are inevitable. According to Check Point, countries can limit the number of forgeries by adopting a QR code system across all vaccine documentation. Even with those measures, however, barriers to implementation will exist for governing agencies and aviation bodies.
According to data published by IATA, international passenger traffic in 2021 is roughly 15% that of pre-covid levels yet one airline reports having as many agents on the ground as during peak summer levels because they have to check all the verification documents surrounding vaccination. However, despite these limitations, Professor Chris Dye, a leading epidemiologist at Oxford University stated on the Oxford University website that “an effective vaccine passport system that would allow the return of pre-Covid-19 activities, including travel, without compromising personal or public health, must meet a set of demanding criteria – but it is feasible.”
In addition to the practical limitations of a vaccination passport, there are ethical considerations in play as well. Currently, there is restricted access to vaccines worldwide, particularly in low-income and lower-middle-income countries. The WHO has warned that the inequitable distribution of the vaccine would deepen existing inequalities and introduce new ones as well. A WHO working paper outlining these considerations goes on to mention that “in the context of unequal vaccine distribution, individuals who do not have access to an authorised COVID-19 vaccine would be unfairly impeded in their freedom of movement if proof of vaccination status became a condition for entry to or exit from a country.”
Even within countries, certain groups are prioritised over others. In particular, low-income communities, rural populations, marginalised groups and younger people are less likely to be vaccinated than the general subset. “Beyond being a distraction from the task of vaccination, the pass could end up creating a two-tier society,” Israel Butler of the Civil Liberties Union for Europe, a human rights watchdog, told the Washington Post in response to the proposed system, noting that the passport had the potential of denying certain individuals’ access to public services.
However, legally, the precedent for vaccine requirements has existed in certain countries for over a century. In 1903, the government of Maine declared that no person without proof of smallpox vaccination was allowed to work at a lumber camp, a decision that was reinforced by the US Supreme Court in 1905, when it ruled that government entities could require vaccines for entry, service and travel, and that states could impose a fine on unvaccinated people. As historian Michal Willrich notes in his book Pox, this occurred around the time when Americans began to conceive of liberty not only as freedom from regulation, but also as freedom to meaningfully and actively participate in public life.
Similarly, public health professionals like Dr. Maya Peled Raz, an expert in health law and ethics at the University of Haifa, argue that with vaccine passports, certain trade-offs are necessary. “That may involve some damage to individual rights, but not all damage is prohibited if it is well-balanced and legitimate in order to achieve a worthy goal,” she told the New York Times. “It’s your choice,” she added of leisure activities. “If you are vaccinated, you can enter. As long as you aren’t, we can’t let you endanger others.”
Tit for Tat
In 2012, upon arrival in South Africa, 125 Nigerians were denied entry for lacking the required yellow fever vaccination documentation, of which 75 were sent home. The next day, Nigeria barred 28 South Africans from entering the country, and deported another 56 illegal immigrants. When searching through the annals of diplomatic history, examples like these are prevalent. According to a column by Max Fisher in the New York Times, countries tend to act in their own diplomatic interests, even when doing so would contradict logic or compromise morality.
The EU has long maintained a policy of visa reciprocity, an objective that the Union pursues in a proactive manner in its relations with non-EU countries. This means that when the EU is considering lifting visa requirements for citizens of a non-EU country, it takes into consideration the visa requirements imposed by that country on EU citizens. And while OECD countries are commonly known to have high entry requirements for citizens from Asia and Africa, those latter regions have the highest levels of entry restrictions themselves. A 2017 analysis of global dynamics in visa reciprocity show that only 21% of countries have asymmetrical visa requirements, with levels of reciprocity increasing exponentially since the 1990s. If a global system of vaccine passports is introduced, countries may determine which passports they accept on the basis of which countries accept theirs.
The notion of quid pro quo diplomacy in regard to Covid vaccine passports is perhaps best exemplified by China, who recently announced that it would expedite entry for foreign nationals who had received a China-made vaccine. This move has caused concern amongst several countries that do not offer the Chinese vaccine but have students and workers who were based out of China before the pandemic. Nicholas Thomas, associate professor of health security at the City University of Hong Kong, speaking to Foreign Policy, attributed this policy to China’s desire to bolster the standing of Chinese vaccines internationally. No vaccine from China has yet been approved by the WHO, and according to Thomas, this move would aim to “ensure that Chinese vaccines remain the preferred choice” for governments globally.
Regional power dynamics
The EU-backed Digital Green Pass would allow vaccinated EU citizens to travel freely within Schengen borders. However, while in theory freedom of movement within the EU is a fundamental priority, the process of establishing a standard for entry has been fraught. Countries such as Greece depend heavily on tourists, with tourism accounting for 20% of the nation’s GDP. Other EU nations such as Germany and France are less dependent on tourism and are therefore reluctant to ease restrictions. How to balance those interests has been a challenge for the trading bloc, which, while announcing the Green Pass, conceded that ultimately the decision of who to allow in or out would remain within the purview of individual nations. These discrepancies could prove challenging for countries such as Hungary which has largely been dependent on China-made vaccines. Under the Digital Green Pass scheme Hungarians travelling within the EU will still likely be reliant on the result of negative PCR tests to enter other countries. On that matter, Minister of the Hungarian Prime Minister’s Office, Gregele Gulyás, stated that “on the basis of reciprocity Hungary will not accept the certificates of countries which do not accept those of Hungary.” Sentiments such as these, while largely to be expected, will compromise the legitimacy of the EU, and undermine the very tenants of its existence.
Within Asia, Singapore and Malaysia attempted to establish reciprocal business travel bubbles in order to facilitate travel between the two countries, but that policy failed to significantly boost the targeted industries. Tourism is a core industry for much of ASEAN, with 51 million interregional visitor arrivals in 2019. Companies such as Air Asia have led the push for regional vaccine passports, citing the need to resume travel in order to enable operations and remain afloat. However, like with the EU, establishing regional standards may prove tricky, with several countries lagging behind on vaccination efforts and possessing different standards for vaccines than those of its neighbours. Singapore-based independent aviation analyst Brendan Sobie recently remarked to Nikkei Asia, that the regional vaccine certificate “will need to be pursued in tandem with other initiatives such as a multilateral pan-ASEAN air travel bubble in order to have a meaningful impact,” while acknowledging it is “a good first step in helping facilitate the resumption of travel between ASEAN countries.”
The haves and the have nots
While rich countries such as Canada have secured the majority of vaccine doses – Canada has 10 doses per citizen – others like Libya and Madagascar have yet to receive a single dose. Hippolyte Fofack, the chief economist at Afreximbank remarked to Rueters, that even if Africa had 100 billion dollars, it would be unable to access enough doses of the vaccine. Because the supply of vaccines is still limited, nations in Africa are reliant on wealthier countries to donate excess vaccines in order to meet domestic needs.
In February 2021, South Africa and India put forth a proposal to the World Trade Organisation to temporarily waive intellectual property rights around products that would contain and treat Covid-19 until herd immunity was achieved. This, they argued, would enable countries in the Global South to manufacture vaccines as soon as possible and confront shortages in supply. The proposal faced criticism from pharmaceutical companies, who argued that it would stifle innovation and restrict future advances in medicine and technology. However, access-to-medicine advocates countered that most of the research behind the Covid-19 vaccines was funded either by charities or national governments. Despite that, and despite the fact that the proposal had the support of more than 100 nations, countries home to major pharmaceutical companies such as the US and the UK, prevented this proposal from moving forward.
Generally, vaccines are produced by private companies that sell them domestically or to foreign governments withthe resources to pay a premium for them. In some cases, producers will make provisions for access in certain markets in exchange for early development funding or for allowing production to occur in a certain country. This system primarily benefits rich nations capable of developing the vaccine themselves or paying for early access. It also bodes well for middle-income countries like India and Argentina that have indispensable domestic manufacturing capacity. However, poor nations that are unable to compete in the open market are dependent on either participating in (often unethical) clinical trials or relying on hand-outs such as the complex vaccine sharing scheme, COVAX. Neither option is preferable. Countries that have enrolled citizens in early vaccine trials will still face long delays in receiving vaccine doses and those reliant on the COVAX scheme are required to pay widely fluctuating prices up-front while also assuming the entirety of the risk if the vaccine fails. With the introduction of vaccine passports, citizens from these countries will be restricted from international travel, especially those who are not digitally integrated.
Creating a passport that would benefit privileged groups will also pose a significant risk to vulnerable populations fleeing war or economic hardship. According to the UN High Commissioner for Refugees, including marginalised groups in vaccination programs is “key to ending the pandemic.” Yet while some refugee host states like Jordan and Lebanon are including refugees in their vaccine rollouts, several others are not. An estimated 9 out the 10 people living in the poorest states in the world may not receive the vaccine until 2022. If vaccine passports become a pre-requisite for travel, those people will be unable to seek asylum unless receiving nations put in place policies that would allow them to be vaccinated at the point of arrival.
Interim position paper: considerations regarding proof of COVID-19 vaccination for international travellers by th WHO
'Vaccine passports' are a common feature in American history
With a large portion of the country getting vaccinated, we are finally seeing light at the end of the tunnel. To protect public health, certain activities will obviously require people to be vaccinated, a kind of policy that has existed in some form or another since the American Revolution. Despite the longstanding established practice, the idea of a "vaccine passport" has people making bizarre comparisons to the Holocaust and tyrannical governments. It is common practice for people to provide their vaccination records in order to go to school, have certain jobs and travel to certain countries. The concept of a "vaccine passport" is just to streamline this process and make it easier for people to show proof of their COVID-19 vaccination. If one doesn't want to get vaccinated, they might just have to forgo participating in certain activities.
Compulsory vaccination laws are justified legally based on the state's compelling interest in protecting the health and welfare of the population. It is common to restrain a little individual liberty in order to protect the safety of the larger society. Consider the Oliver Wendell Holmes quote, "The right to swing my fist ends where the other man's nose begins." Our liberty must be restrained if said liberty has the likelihood of putting others at risk. This applies to gun laws, traffic laws, or bringing shampoo bottles on airplanes. If a person doesn't want to get vaccinated, that is their choice. But they likely forfeit traveling, attending schools, or having certain jobs.
It is common to restrain a little liberty in order to protect the safety of the larger society. Consider the Oliver Wendell Holmes quote, "The right to swing my fist ends where the other man's nose begins."
Compulsory vaccination policies in this country began during the American Revolution. Smallpox was a huge threat to the Continental Army and word of the disease was actually halting enlistments. In order to protect soldiers and the war effort, General Washington ordered all new recruits receive the "variolation" for smallpox in 1776. The policy was successful at eradicating smallpox among soldiers, which helped the Continental Army defeat the British invasion at Saratoga.
The first law that required the general population get vaccinated was passed in Massachusetts in 1809. The state empowered local boards of health for towns to require free vaccinations of people over 21 if the boards felt it was necessary. If a person refused, they had to pay a $5 fine (about $100 in today's money). States across the country followed with their own compulsory smallpox vaccination laws though the specifics varied widely. Some only required compulsory vaccinations in the midst of an epidemic. Some only required vaccinations for children attending schools.
New York City exercised particularly broad power in allowing health officials to enforce vaccinations or quarantines. As a busy international harbor, the city felt particularly threatened by incoming diseases. As a result, immigrants and ships were often required to quarantine. Unfortunately, these policies often took on a distinctly anti-immigrant and nativist turn. Public health officials often blamed poor immigrants for spreading diseases rather than engaging in education to encourage vaccine compliance. Common policy in the late 19th century was to place a yellow flag in front of an infected building and not allow anyone in or out. However, there weren't clear guidelines on forcing a person to comply with a vaccination if they didn't want to. As a result, in 1894, Brooklyn's top health official Z. Taylor Emery would often enforce quarantines, to the point of not allowing provisions to be delivered, on those who refused being vaccinated. Emery's arbitrary and coercive policies resulted in backlash but the appeals court supported Emery's rationale of protecting the public.
In 1905, the question of compulsory vaccination laws made it to the United States Supreme Court in Jacobson v. Massachusetts. At the time, Massachusetts was one of 11 states that had compulsory vaccination laws. Jacobson was a Swedish immigrant who had a bad experience with a childhood vaccination. He refused the smallpox vaccination as an adult in Massachusetts. Jacobson was prosecuted and fined for refusing. He challenged the fine, claiming it was an invasion of his liberty. In a 7-2 decision the Supreme Court ruled that mandatory vaccination laws are not arbitrary or oppressive, as long as they don't "go so far beyond what was reasonably required for the safety of the public." Jacobson was affirmed in 1922 in Zucht v. King to support a school district refusing admittance to a student who was not vaccinated. That ruling was used as precedent in 2020 concerning cases resulting from COVID-19 policies.
There is a complicated history in the United States for compulsory healthcare with vulnerable communities. Coercive policies to force vaccinations might have produced results, but in 2021, we know better ways to encourage vaccination and public safety.
Education and restricting participation in certain activities, jobs and schools will likely be the vaccine policies going forward. We don't yet know exactly what activities will require proof of vaccinations, but such policies are not anything new. A "vaccine passport" on your phone will only serve to make the existing process of vaccine proof for schools, jobs and travel a little easier. This is a far cry from fascism or tyranny.