Licence to live

Ragnhild Ørstavik About the author
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People who have been infected with COVID-19 avoid quarantine after exposure to infection or a stay abroad. The regulation is a sensible one, but it should not be a first step towards discrimination on the grounds of immunity.

Photo: Einar Nilsen

Once in the 1830s, the German immigrant Gustav Dresel arrived in New Orleans and applied for a job as a bookkeeper. He was not given the job. He had not had yellow fever, the disease that swept through the city in 22 epidemics during the 1800s and killed around 150 000 people (1). As an alternative to other protective measures against infection, the wealthy, white segment of the population ensured that only those who had had yellow fever were able to work, take out life insurance and live where they wished. Poor people desperately seeking work occasionally took care to become infected themselves, even though the probability of dying was 50 %.

In Norway, the measures taken against the spread of COVID-19 are now (in May 2020) being eased. There are now exemptions given for six months from the duty to quarantine for persons who can document that they have undergone infection with SARS-CoV-2 (2). Currently only RT-PCR (reverse transcription polymerase chain reaction) is recommended, i.e. the test for the virus itself, and hence not the tests that detect antibodies after individuals have had the infection (3).

This type of exemption makes sense. If one assumes that a person cannot be infected, it is inappropriate to deny them the opportunity to return to work, travel, meet friends or in any other way to live as normally as possible in an abnormal time. And surely a logical exemption is very far removed from a two-hundred-year-old story from a Southern state of the USA?

Perhaps, but some countries want to go further: in the UK, Germany and the USA, the introduction of so-called immunity passports is being discussed. Inhabitants who test positive for antibodies to SARS-CoV-2 are to be given a passport which provides them with broad exemption from restrictions to limit infection (4). The World Health Organization has warned against the scheme, primarily because the immune response to the virus is not well enough known, and antibody tests have insufficient validity (5). The authors of an ethical analysis published in JAMA claim that such passports are otherwise ethically defensible (6): A scheme that limits protective measures against infection to apply only to those who may in fact represent a health risk to others, is consistent with a ‘least restrictive alternative’ principle, whereby the freedom of the individual is not restricted more than necessary. The authors compare the immunity passports with driver’s licences and occupations where special requirements are placed on the health of the worker because other people may otherwise be threatened (for example pilots) (6). When society is locked down, holders of immunity passports can nevertheless go to restaurants, gyms and concerts, and thereby ensure that others can earn money, and that tax revenues can be collected. Work that requires close contact with vulnerable groups can be confined to those who cannot infect others.

Are we to have a society where the population is divided into the over- and underprivileged on the basis of a blood test?

The resistance is immense: Are we to have a society where the population is divided into the over- and underprivileged, this time not based on religion, skin colour or ethnicity, but on the basis of a blood test that exempts you from restrictions that others must adhere to (4, 7)? What will people do to achieve such a status? Will the scheme encourage healthy people to allow themselves to become infected, or to obtain fake passports (7)? Perhaps not in countries like Norway, where the welfare state is one of the most important cards we have against the virus. However, in countries where the choice is between not being able to feed one’s children, and undergoing a viral infection from which one will probably recover, the situation is of course different. And in a world where most things can be bought for money, an illegal market will soon be established for documents that ensure income and personal freedom (3, 4, 7).

As a minimum to prevent a type of immunity passport from leading to further marginalisation of the poor and vulnerable, the prerequisite for differential treatment of the immune and the others must be a free and easily available testing service. This requires a far larger capacity than the vast majority of countries currently possess. Moreover, until now it appears that there are far too few people with immunity to meet the need for nursing home staff or to kick start the economy (7).

When, or if, a vaccine becomes available, the situation will change. A safe vaccine that is offered to everyone opens the possibility to require vaccination status to be able to perform certain types of work or cross national borders. In the meantime, documentation showing that people have had the infection should be issued with caution. In Norway, the demand is already considerable because many people wish to travel to Sweden to shop for food (8). If the incentives are stronger than cheap meat and sweets, we may find ourselves in a situation that few had foreseen and no one had wished for.

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