II. Vaccine passports: background

Currently, there are ninety-one vaccines in clinical trials on humans, with twenty-seven having reached phase 3 of large-scale efficacy tests.Footnote ⁵ The Pfizer COVID-19 vaccine (BNT162b2) was the first vaccine to receive the WHO’s Emergency Use Listing (EUL) for SARS-CoV-2, having recently been joined by the two versions of the AstraZeneca/Oxford COVID-19 vaccine manufactured by the Serum Institute of India and SKBio, the COVID-19 vaccine Ad26.COV2.S developed by Janssen (Johnson & Johnson) and the Moderna vaccine (mRNA-1273) developed by Moderna.Footnote ⁶ On 7 May 2021, the WHO granted emergency use authorisation to China’s Sinopharm. Other vaccines that have applied for WHO EULs include Russia’s Sputnik V and China’s Sinovac.Footnote ⁷ The Pfizer COVID-19 vaccine and the Moderna vaccine have also been approved for emergency use in the USA, the European Union (EU) and elsewhere.Footnote ⁸ Clinical data suggest that these vaccines have varying efficacy in preventing the acquisition and transmission of SARS-CoV-2, ranging from 50% to 90%, although all approved vaccines prevent the most severe forms of the disease and hospitalisation. Nevertheless, at the time of writing, there is insufficient scientific evidence on the duration of protection offered by these SARS-CoV-2 vaccines, as well as on the extent to which these vaccines prevent the acquisition and transmission of variants of SARS-CoV-2. It is also important to note that a conceptual difference exists between immunity and vaccine passports: the former refers to the detection of antibodies to SARS-CoV-2,Footnote ⁹ while the latter refer to proofs of full vaccination against the virus as a condition for international travel.Footnote ¹⁰

At the time of writing, the COVID-19 Vaccine Global Access Facility (COVAX) – co-led by the WHO, Gavi (a public–private partnership focused on improving global access to immunisation) and the Coalition for Epidemic Preparedness Innovations – has delivered 71 million doses to 125 countries, currently falling short of its target of 2 billion by the end of 2021.Footnote ¹¹ The overall global distribution of vaccines remains uneven: of 1.6 billion doses administrated worldwide, 60% are concentrated in the advanced economies, with the majority being secured through Advanced Purchase Agreements.Footnote ¹² Canada, for example, has enough vaccines for nearly six times its population. The political economy of COVID-19 vaccine distribution thus reflects a deeply divided world where vaccine passports, if improperly administered, could further perpetuate global patterns of exclusion. Insofar as the equitable distribution of vaccines remains a key determinant of the rate of worldwide recovery from the pandemic, the discourse on vaccine passports as infused by geopolitics may mask the deeper structural issues (eg the monopoly of knowledge through intellectual property protection, global inequalities, governments’ failures in strengthening public healthcare capacities) that have predated the emergence of COVID-19. While the Biden administration has announced the USA’s commitment to waving patent protections for COVID-19 vaccines at the World Trade OrganizationFootnote ¹³ and the G20 leaders have suggested voluntary licensing instead,Footnote ¹⁴ the world would still need to expand global manufacturing capability and facilitate the necessary knowledge transfer to have a real impact.

Caught in the strategic competition and economic rivalry between the USA and China, Taiwan’s peculiar international status reflects a binary world of inclusion and exclusion. Insofar as the discussion of vaccine passports is closely interwoven with the rhetoric of vaccine diplomacy, it also reveals increased geopolitical tensions around the world. New terms – such as “vaccine apartheid” and “vaccine nationalism” – that have entered the public discourse over the past year reflect anxieties surrounding the global health political economy more broadly. The emergence of these new terms also reflects a dysfunctional global health system, which some scholars perceive as a legacy of colonialism that embeds current global inequalities.Footnote ¹⁵ As current hopes for returning to normal public life hinge upon vaccinating the population swiftly, the myriad legal and ethical concerns surrounding the rollout of vaccine passports (including the encroachment on privacy and autonomy, the growing digital divide and the deepening of inequalities) must also be considered within a wider discussion of other forms of international inequality in a multipolar world.

III. Taiwan and its long road to vaccination

Within Taiwan, the discussion over digital vaccine passports remains relatively limited compared to in other countries, partly because of the relative success of the domestic pandemic response that has diminished the urgency for the government to reopen its borders as long as the situation remains dire internationally. Like its neighbours in East Asia such as Japan and South Korea, Taiwan’s pandemic response consists of the strong enforcement of traditional public health measures (eg universal face mask wearing, effective contact tracing) that, combined with digital technology, have proved largely effective at containing the spread of SARS-CoV-2. As an island nation, border control is relatively easy in Taiwan as compared to other countries with land borders. Taiwan adopted a risk-based approach to international border control when SARS-enCoV-2 was first identified in Wuhan, China. Instead of outright prohibiting the entry of inbound passengers from China, Taiwan first implemented on-board inspection of inbound passengers from Wuhan, then expanded to the temporary suspension of the entrance of foreign nationals from China.Footnote ¹⁶

In many ways, Taiwan’s strict enforcement of traditional public health measures – which was not without criticismFootnote ¹⁷ – yielded successful pandemic management until late April 2021. Strict border control measures – where inbound passengers are required to undergo fourteen days of mandatory quarantine either in designated hotels or at homes, for instance – have kept the country relatively free of SARS-CoV-2.Footnote ¹⁸ However, as mandatory quarantine days were relaxed for flight crews in April 2021, cluster of cases soon erupted, mostly concentrated in the two major cities in Taiwan.

Like elsewhere, the Taiwanese government also faces political pressure to reopen, particularly as the island has close economic ties with China.Footnote ¹⁹ Even though the markedly low number of cases attests to Taiwan’s effective pandemic management and response so far, challenges are ahead. Prior to the outbreak that began in late April, the island’s pandemic response has been exemplary in many aspects; this also meant that Taiwan had a lower priority for vaccine distribution through the COVAX Facility when compared to other countries and economies – and rightly so, as the Facility prioritises vaccines in terms of the “most in need” instead of “most in want” worldwide. Yet the recent outbreak in Taiwan underscores the difficult of achieving total elimination of SARS-CoV-2 without vaccines. If the reopening of international travel is premised on the condition of vaccination passports, this could also exacerbate the global shortage in vaccines and would adversely reward those countries with market power and access to vaccines, further diminishing the already limited global solidarity.

Cross-strait tensions also inform the domestic vaccine discourse, which is also strongly shaped along geopolitical lines. The opposition party, Kuomintang (KMT), which has a pro-China stance, has also made the party a strong advocator for Chinese-made vaccines.Footnote ²⁰ This is despite China’s Sinovac having a reported efficacy of around 50% in both Brazil and Chile.Footnote ²¹ Recently, the Chinese Center for Diseases Control and Prevention has acknowledged that Chinese-manufactured vaccines fall short of expected efficacy.Footnote ²² As the scientific validity of these Chinese-made vaccines is widely questioned, the Taiwanese government has repeatedly rejected the KMT’s proposal based on scientific grounds.Footnote ²³ Domestically, the law prohibits the importation of Chinese-made vaccines and other biological products.Footnote ²⁴ However, former President Ma Ying-Jeou, of KMT, has claimed that the government has rejected the Chinese-made vaccines based on political grounds alone.Footnote ²⁵ Nonetheless, public acceptance of Chinese-manufactured COVID-19 vaccines remains low according to one report.Footnote ²⁶

Like elsewhere in the world, imported vaccines still need to undergo a rigorous regulatory process, with an Emergency Use Authorisation granted for the AstraZeneca vaccine on 20 February 2021.Footnote ²⁷ Currently, around than 517,000 doses of the AstraZeneca vaccine are available island-wide, making it the only vaccine available for preventing SARS-CoV-2 in Taiwan. However, the uptake for the AstraZeneca vaccine has been overshadowed by its linkage with rare blood clots, which adds to widespread vaccine hesitancyFootnote ²⁸ ; however, the recent outbreak has also seen a surge in demand, especially amongst first-line healthcare workers. Overall, the island remains vulnerable to the virus, as only 1% of the population is vaccinated, largely due to the low availability of vaccine supplies.Footnote ²⁹

Attempts to secure the Pfizer COVID-19 vaccine manufactured by Germany’s BioNTech has met with notable difficulties, where the ability to secure and distribute vaccines remains largely dependent on market power and, in Taiwan’s case, political sway. While the government is reluctant to disclose the negotiation details with BioNTech, the media report that Taiwan’s procurement of the Pfizer vaccine is also infused with geopolitics. According to media reports, possible pressure from China has made it less likely for Taiwan to be able to purchase the Pfizer vaccine from the manufacturer.Footnote ³⁰ For Taiwan, hopes of achieving herd immunity thus now hinge upon domestic production currently in clinical trials.Footnote ³¹

To increase the voluntary uptake of vaccines, the Taiwanese government has increased public health campaigns and education. However, the vaccination rate remains slow, which can be explained by the vaccines’ limited accessibility and availability, as well as the general public’s perception of vaccine safety and effectiveness. Vaccine hesitancy remains a key barrier to the national vaccination efforts in Taiwan. According to one report, only 60.3% of Taiwanese citizens are willing to be vaccinated against SARS-CoV-2, which is below the international average of 74%.Footnote ³²

At the same time – and as the COVID-19 pandemic stretches into a second year – vaccine procurement has also become an ideological battlefield between liberal democratic states and authoritarian regimes. Caught in the crossfire between the USA and China, Taiwan’s increased geopolitical importance and its relative success in pandemic management have made international headlines.Footnote ³³ Indeed, Taiwan’s peculiar political status has become further complicated by the pandemic. China has long claimed Taiwan as part of its territory, a claim strongly disputed by Taiwan, as the country operates through an independent democratic system and has never been under the control of China.Footnote ³⁴ China has consistently wielded its political and economic influence on Taiwan through soft power: before the emergence of COVID-19, China exerted considerable soft power over 400,000 Taiwanese businesses in China through tax incentives and considerable subsidies. During the pandemic, Chinese-produced vaccines became the latest state apparatus used to lure Taiwan, in that Taiwanese based in China were given priority for the Chinese COVID-19 vaccines.Footnote ³⁵ Such a tactic is consistent with China’s overall vaccine diplomacy, which has seen over sixty countries granting approval for China’s vaccines.Footnote ³⁶ China has also attempted to use vaccines to lure Paraguay and Honduras – two of Taiwan’s limited allies – to sever diplomatic ties with Taiwan.Footnote ³⁷ Despite the lingering doubts over the efficacy of these vaccines, the limited global supply chain for WHO-approved vaccines has seen countries – mostly lower-income countries – embracing the extension of China’s “Health Silk Road” amidst the pandemic.Footnote ³⁸

Prior to the April outbreak, many commenters assumed that Taiwan’s effective pandemic management meant that the island had the luxury of time not afforded to many countries that were in a race against time to vaccinate their populations swiftly. However, these views have been drastically challenged with the sudden spike in local cases. Although the government has acknowledged that vaccine passports might be on the horizon for the country, the government also experimented with travel bubbles with Palau, which has zero case of SARS-CoV-2 infection.Footnote ³⁹ Yet, as domestic cases increase daily in Taiwan, flights between Taiwan and Palau are also cancelled for now.

Yet, as population-wide vaccination becomes deemed to be a necessary pathway to mitigate the pandemic, while global vaccine supply remains limited vaccine passports risk becoming discriminatory based upon access. Introducing vaccine passports as a condition for entrance into a country could also lead to potentially discriminating against those with medical reasons not to be vaccinated (ie individuals who are immunocompromised or allergic to some vaccine components) or those who choose not to be vaccinated. Furthermore, if airlines or governments require digital vaccine passports as a requisite for boarding or entrance, this could also deepen the digital divide and potentially create a two-tier world based on vaccination status, as other papers in this special issue also argue.

At the regional level, the discourse on vaccine passports remains at an early stage in most East Asian countries.Footnote ⁴⁰ Nevertheless, there is a critical need to interrogate the use of vaccine passports for cross-border travel, whether at the regional or the international level. The discussion on the use of vaccine passports that has begun in the Association of Southeast Asian Nations (ASEAN)Footnote ⁴¹ is in its early stages, but unlike in the EU, ASEAN regulations on data protection remain weak, adding a further layer of challenge in the ASEAN context.Footnote ⁴²

As others in this special issue note, at the national, regional and international levels, the discussion over digital vaccine passports may mask complex technological challenges as a deceptively simple solution to the reopening of international borders. However, harnessing digital technology for vaccine passports must first overcome the considerable technological challenges ahead: first, different databases across countries must be made interoperable; second, access to countries’ official records of complete vaccinations with links to individuals’ health records must be secure and free from cyberattack; and third, a common standard across countries for cross-border health data transfer must be accepted.Footnote ⁴³ Likewise, legally, the use of digital vaccine passports will need to be in compliance with personal data protection regulations within the jurisdictions in which they operate (or, in most cases, also across jurisdictions). Privacy, data protection and autonomy risk being the first casualties if they are not addressed appropriately, as international pressure for adopting vaccine passports is building.

Protecting sensitive data remains a highly scrutinised issue in Taiwan. Previously, the government has planned to introduce a national scheme of digital identification cards, but the initiative was widely opposed chiefly due to the lack of legal safeguards to prevent unwarranted access by the government.Footnote ⁴⁴ As a result, the government has halted the initiative indefinitely. As the COVID-19 pandemic unfolds, the Taiwanese government has linked different databases to enable real-time disease surveillance, raising legal and ethical concerns.Footnote ⁴⁵ However, for now, vaccination status for SARS-CoV-2 is recorded on a physical card that is not linked to health records. It should also be noted that the Personal Data Protection Act (PDPA) that governs the collection, processing and use of personal data would also be applicable to the cross-border transfer of data if international vaccine passports are adopted in Taiwan, where the PDPA is based on the General Data Protection Regulation (GDPR) in the EU.Footnote ⁴⁶

IV. The World Health Organization and the politics of global health

Along with the exposure of geopolitical fault lines, the COVID-19 pandemic has shattered many assumptions about the ability of international organisations to achieve global cooperation when faced with collective action problems. Established in the aftermath of the Second World War, the WHO is tasked to act as the coordinating global health agency when infectious diseases of international concern arise.Footnote ⁴⁷ The WHO has thus far opposed the use of immunity passports against the background of diminishing trust and credibility, as the reputation of the agency has suffered considerably from its obvious missteps when the virus first emerged.Footnote ⁴⁸

At the beginning of the pandemic, the WHO strongly advised against the use of immunity passports, citing the lack of scientific evidence to support their basis.Footnote ⁴⁹ One year on, at the sixth meeting of the International Health Regulations Emergency Committee for the COVID-19 pandemic, the WHO remains opposed to requiring proof of vaccination for international travellers.Footnote ⁵⁰ Drawing attention again to the concerns of vaccine equity and scientific validity, the WHO Director-General issued the following Temporary Recommendation under the Public Health Emergency of International Concern (PHEIC): “At the present time, countries should not introduce requirements of proof of vaccination or immunity for international travel as a condition of entry as there are still critical unknowns regarding the efficacy of vaccination in reducing transmission and limited availability of vaccines”.Footnote ⁵¹ For now, then, the WHO remains adamantly against introducing proof of vaccination as a condition of entry, which may exacerbate inequities across and within countries.Footnote ⁵² The stance is reiterated in a WHO interim paper: “In the current context, introducing a requirement of vaccination as a condition for travel has the potential to hinder equitable global access to a limited vaccine supply and would be unlikely to maximize the benefits of vaccination for individual societies and overall global health”.Footnote ⁵³ Nonetheless, most recently (and recognising the potential for facilitating the reopening of international borders), the WHO has formed a Smart Vaccination Certification Working Group due to the growing interest in harnessing digital technologies for documenting vaccination status.Footnote ⁵⁴

It is important to note that here the requirement of proof of vaccination as a condition for international travel under the 2005 International Health Regulations (IHR) – the governing legal architecture for international infectious diseases control for 196 countries – is not without precedent. In the past, the WHO’s Yellow Card for cholera, plague and typhoid has been extensively used to verify the vaccination status of international travellers.Footnote ⁵⁵ While the IHR permit State Parties to implement additional health measures that “achieve the same or greater level of health protection than recommended by the WHO”, these health measures must also be non-discriminatory, among other human rights considerations. Under the IHR, the requirement for vaccination is guided by Article 31 and is limited to specific diseases provided in Annex 7, specifically to yellow fever.Footnote ⁵⁶ The WHO could thus issue a temporary recommendation that is issued every three months when a PHEIC is declared, as in the case for poliovirus. Issuing a temporary recommendation would legally permit the use of vaccine passports internationally in the context of COVID-19. However, the WHO has stated that for the organisation to make such a recommendation it would need to be premised on the universal availability of vaccines, which must be approved under emergency use by the WHO.Footnote ⁵⁷

Despite being the global health agency, the WHO is not immune from geopolitics. With Sinopharm recently being added to the WHO’s EUL with an efficacy rate of 78.1% – a win for China’s geopolitical clout as perceived by some commentatorsFootnote ⁵⁸ – it remains to be seen whether China will donate a sufficient amount to the COVAX Facility to help ease the global shortage of vaccines, as China also faces domestic shortage.Footnote ⁵⁹ Anti-Chinese sentiment that is prevalent in some South-East Asian countries such as in Vietnam, which is currently experiencing a surge in local cases, also underpins resistance to Chinese-made vaccines.Footnote ⁶⁰ Furthermore, the EU’s exclusion of Chinese- and Russian-made vaccines from its soon-to-be-launched COVID-19 Certificate also marks challenges for the rollout of international vaccine passports.