By Ifeoma Ajunwa
As scientists develop increasingly accurate tests for COVID-19 immunity, we must be on guard as to potential inequities arising from their use, particularly with respect to their potential application as a prerequisite for returning to the workplace.
A focus on immunity as a yardstick for return to work will only serve to widen the gulf of economic inequality, especially in countries like the U.S., which has severe racial health care disparities and uneven access to effective healthcare. This focus could also serve to diminish societal support for further understanding and curtailing the disease.
On November 12th, 2020, the New York Times reported that a new type of blood test to detect T cells could be more accurate in detecting a person’s immunity to the coronavirus. The new blood test, which is developed by Adaptive Biotechnologies, is superior to antibody testing, as it can detect a T cell response for at least 6 months, whereas antibodies may become undetectable sooner than that. Just a few days later, on November 18th, 2020, the Times published the findings of a new, not-yet-peer-reviewed study whose findings suggested that COVID-19 immunity could last for years.
Antibody, or serology, tests are currently used as an imperfect measure to presume COVID-19 immunity. These tests check for the presence of antibodies thought to result from a Sars-CoV-2 infection, the virus that causes COVID-19. However, as the FDA has noted, at this time, researchers are not certain that the presence of such antibodies means that the individual is immune to the coronavirus. Furthermore, in some cases, the antibodies were found when there had not previously been a Sars-CoV-2 infection. In these instances, the presence of antibodies was attributed to other, similar viral infections and certainly could not be relied on as a sign of COVID-19 immunity.
The obvious utility of the new T cell test is for public health purposes – determining immune response and possible immunity to the coronavirus is helpful for combating its spread. But another use case, determining immunity prior to a return to the workplace, is fraught with ethical considerations.
Early on in the pandemic, several governments called for literal “immunity passports” to be accorded those with detected antibodies for Sars-CoV-2 and which could allow those individuals to travel freely and return to work. However, in April 2020, The World Health Organization (WHO) released guidance noting that, given the lack of adequate scientific evidence about the effectiveness of antibody-related immunity, the efficacy of an immunity passport could not be guaranteed. In fact, there is a heightened risk that individuals who assume they have immunity from the coronavirus, due to inaccurate antibody testing, may be more likely flout public health guidelines, leading to more infections.
This guidance misses an important point. Even as we develop better tests to detect COVID-19 immunity, the important question is not how accurate those tests are. The more important quandary is how society should treat individuals who either have genetic immunity or acquired immunity.
History has shown that immunity to disease as passport to work can draw a dividing line based on both socio-economic factors and racial group memberships. Writing for Slate, Rebecca Onion notes that “[w]hen yellow fever ravaged 19th-century New Orleans, wealthy white people who ‘acclimated’ [i.e., developed immunity] were rewarded.” White people who had survived yellow fever benefited from “immunoprivilege,” while others suffered social and economic repercussions. In the 21st century, a focus on coronavirus immunity rather than prevention of infection could play out similarly.
To acquire immunity, an individual must first survive the disease. Surviving the disease necessities adequate healthcare. Yet, access to healthcare services in the U.S. is unequal. While some COVID-19 patients, like President Trump, are able to receive high levels of healthcare (and even experimental drugs), others lower on the socio-economic spectrum do not have health insurance and can only receive emergency care. Thus, immunity as passport to work would only serve to increase inequality as it would reward those who could afford the care needed to survive.
It is also worth noting that people of color are generally more likely to die of the disease than their white counterparts. Could this lead to a social (even if not scientifically proven) view that white people have greater immunity to the disease than others? If so, imagine how this social view could play out in racial employment discrimination as businesses re-open. Past research shows that racial minorities have had to contend with genetic discrimination in the workplace.
Even as more accurate tests are developed to detect COVID-19 immunity, society must continue to grapple with the ethical questions surrounding the use of those tests. We must remain on guard to ensure that immunity to the coronavirus is not used as a wedge to further separate the haves and the have-nots and to widen the chasm of inequality.
Ifeoma Ajunwa is an Associate Professor (with tenure) at Cornell University’s Industrial and Labor Relations School and Cornell Law School and a Faculty Associate at the Berkman Klein Center at Harvard Law School.