S1E33 / The Privilege of Immunity / Kathryn Olivarius, Juanita Mora, Esha Bhandari

Hi everyone, I'm Julie Levy and I'm an intern working on Epidemic with Just Human Productions. Nominations for the 2020 People's Choice Podcast Awards opened on July 1st. To show your support, please go to podcastawards.com and nominate us in the health category. That's podcastawards.com.

Thank you. I'm Dr. Celine Gounder, and this is Epidemic. Today is Tuesday, July 7th. Dr. Juanita Mora is a first-generation Mexican American living in Chicago.

My dad was a butcher, my mom a stay-at-home mom. My grandparents were part of the Bracero Movement, which is they worked the lands here in the United States and It led me to work really hard and be very involved with the Latino community.

Health officials in Chicago reported the city's first COVID case on January 30th. Over the following weeks, Dr. Juanita Mora saw it take its toll on the Latinx community in Chicago. Juanita runs a private allergy and immunology practice, and so she decided to open it up to the community for COVID testing.

I wound up getting a lot of patients who, for example, had outbreaks at tortilla factories, at grocery shops, at meatpacking companies as well too, where 7 or 8 of their coworkers were sick.

Her services were in high demand, but she saw a lot of anxiety in her patients, especially those who were undocumented.

And what wound up happening is some were threatened and said, we're not planning to do social distancing, we're not planning to institute any actual safety measures. Here's a job if you want it, and if you don't, then feel free to leave this job.

Walking away from a job wasn't an option for most of her patients, but there wasn't much they could do to demand safer working conditions of their employers.

These workers don't have actual legal status, so they know that they have nowhere to complain to, and they fear deportation. They fear losing a paycheck as well, too.

And then Juanita noticed something new. Employers started to require some of the workers Juanita was caring for to prove they didn't have COVID before they could come back to work.

They had already done the nasal swab and had either come back positive or negative, and now they were actually wanting to go back to work, and they wanted guidelines as far as how to safely get back to work.

This is something we've seen around the world since the beginning of the pandemic. Some people keep coming up positive for COVID on the PCR tests long after they've recovered. But to get back to work, they've got to show evidence of recovery.

That's one of the things that I started encountering is people who wanted me to write, employers who wanted me to write and say, well, they already had it and they can't get it again.

And that's where antibody testing comes in. It's important to understand that these tests don't prove someone is immune to reinfection, but antibody tests are evidence that someone has recovered and no longer poses an infectious risk to others. But it's not a stretch to imagine how such antibody tests could be used by employers in other ways.

Could a special type of COVID passport pave the way for some people to return to work or travel?

Some officials have floated the idea of immunity passports.

An immunity passport might be the answer here. It's an idea other countries like the UK and Chile are looking at.

In theory, someone with COVID antibodies could get an immunity passport they'd present for travel, work, or to attend large gatherings, for example. This week on Epidemic, we're discussing all that could go wrong if officials were to move forward with an immunity passport system. And to understand the potential consequences, we're going back to the antebellum South, to 19th century New Orleans. <LYRICS>In the evening by the moonlight, no one here won't mind your drinking.</LYRICS> As the capital of the slave trade, New Orleans was thriving.

But it was also the nation's deadliest city.

This is Katherine Olivarius. Katherine's an assistant professor of history at Stanford University.

Back in April, she wrote an op-ed in the New York Times titled "The Dangerous History of Immuno-Privilege." Between 1803, so the Louisiana Purchase, and the Civil War in 1861, New Orleans experienced 22 full-blown summertime epidemics of yellow fever.

Yellow fever is vicious. It's a virus spread by mosquitoes. Severe cases cause liver failure and jaundice, literally turning the whites of your eyes yellow. Fever, chills, and nausea are other symptoms, but one really sets it apart.

Black vomit. At the end of a person's illness with yellow fever, the sort of most famous symptom was that they would regurgitate this coagulated blood that looked quite a, a lot like coffee grounds.

The virus arrived in the United States in 1793 when a group of refugees fled an outbreak in the Caribbean and landed in Philadelphia. An estimated 10% of Philadelphia's population died in that first outbreak. Soon, the disease spread to other coastal cities. But no city would suffer as much as New Orleans.

In 1804, for example, the first year that America had taken control over New Orleans and Louisiana, a very, very terrible epidemic swept through town, killing thousands of people.

New Orleans was an attractive destination for people looking to strike out on their own. Immigrants arrived in droves, and this big influx of new people dramatically increased the spread of the disease.

These people had no immunity or exposure, previous exposure to yellow fever in the past. And we see these death tolls reaching new, you know, higher and higher proportions. In 1853, for example, the year of New Orleans' worst epidemic, 12,000 people died over the course of 3 months. This is one of the worst natural disasters in American history.

This was a really deadly century in US history. Cities across the young nation were battling myriad epidemics of infectious diseases. There were lots of ways cities tried to curb the spread of disease back then.

When we think about quarantines, I think people often think about sort of there's a barrier almost, you know, stopping all ships coming in. You know, they actually are quite complex. Often there's this sort of quarantine ground. There can be ships out in the harbor or, you know, in port. On the river where infected people can be held for a period of time. For example, in New York Harbor, they will have, you know, a smallpox quarantine. They'll have a typhus quarantine. These are different ships.

Other cities shut down their ports and businesses, kind of like we're doing with coronavirus today. But New Orleans was reluctant to take these steps.

These are expensive, and why spend money on delaying the inevitable?

And so politicians there took a different, more fatalistic approach.

The attitude became essentially that we can't stop yellow fever, but we have to figure out a way to make society work in spite of mass death.

Kathryn calls this idea immunocapital.

It's sort of a superpower. Immunocapital is the sort of ability to convince others that you are immune and leverage your immunity for greater social, economic, and political power.

Back then, developing immunity was known as being acclimated, and it was difficult to prove because at the time, no one knew if surviving yellow fever actually made them immune.

The long and short of it in some sense is that you didn't actually totally know. You had a pretty good sense, you thought probably that you were, but you were— there's always a sliver of a doubt in your mind.

And sometimes people didn't even know if they'd had yellow fever. It could have been malaria, cholera, typhus, typhoid, or tuberculosis. They all have overlapping symptoms, and they were all common in the 19th century.

Part of the sort of social code of New Orleans and a part of, you know, being able to leverage immunocapital was in your ability to convince others that you were immune.

Maybe you'd become immune in the first outbreak, back in the early 1800s. Maybe you'd become immune last week. Either way, convincing those around you took on a life of its own.

People will be boasting loudly about they were acclimated back in 1833 or back in 1817, and they have these, they sort of incorporate these kind of stories as like war stories almost. And they will describe their symptoms in great detail.

For young white men, it was their only hope of employment. Let's pretend you're writing up a resume for a job at this time in New Orleans. Survived yellow fever would be right at the top. Your most valuable qualification didn't have anything to do with your experience on the job. It was your immunity. Without that, good luck.

You know, it's fundamentally about sort of placing value on people who are acclimated or immune, because from bosses' perspectives, and, you know, in this incredibly lethal and sort of mercenary city, It wasted time and energy to train somebody for a job, you know, in May, only to watch them sicken and die by the autumn.

It was a cruel calculus.

The boss would ask you, so describe your symptoms, go through and convince me that you know what you're talking about. You know, how many years have you been in New Orleans uninterrupted? How many summers have you passed? Are your parents from here? Can you produce a doctor's certificate? If you're unacclimated, you couldn't get a job.

It impacted everything else too. Housing.

You couldn't live in certain places.

Marriage.

Fathers would not let their daughters talk to unacclimated men, you know, lest she fall in love with him and, you know, he die and she'd be left heartbroken.

Everything.

You're left in this sort of liminal, insecure state financially. And, you know, it deeply impedes your ability to be sort of socially accepted in this place. If you are acclimated, however, if you're rich, if you're white. This is a mark of permanence.

For young white women, being acclimated raised their marriage prospects. For free people of color—and there were many in New Orleans at the time—being acclimated offered a greater shot at prosperity. For enslaved people, however, acclimation had little benefit. Immunocapital instead created another way for white people to justify slavery.

Doctors, pro-slavery thinkers, politicians, laypeople—they all sort of forwarded this idea that was prevalent around the Atlantic world, but especially in the American South—that all Black people were naturally immune to yellow fever. It's not true. There is zero epidemiological basis for this.

Just an economic one.

So with this idea that all Black people were naturally immune, you can justify racial slavery on an unprecedented scale. You can say that slavery is natural, even humanitarian, as people said back then, because it kept white people away from spaces and labor that would kill them.

White men didn't even buy their own lies.

So on the one hand, you have this mythology that all Black people are naturally immune to yellow fever. But in the slave market, no slaveholder would purchase a person without an express guarantee of acclimation.

When enslaved people were acclimated, they became significantly more valuable.

Selling for between 25 and 50% more than unacclimated slaves.

Of course, the enslaved person never benefited from their own immunocapital.

So in some sense, Black immunity became white capital in this society.

This focus on yellow fever immunity created a system where the mission was clear.

It was considered your sort of duty first to get acclimated. For poor people, you end up being sort of forced into making choices, these terrible choices that maybe people should never have had to make in the first place, where you, you know, have to actively sort of seek sickness as this pathway to prosperity.

If public officials today were to move forward with any plans for immunity passports, the same dilemma could soon become our new reality.

The only way to show that proof of immunity is to get COVID-19 and to hope that you won't get COVID-19 so badly that you're either hospitalized or even worse.

This is Ayesha Bhandari, senior staff attorney at the ACLU's Speech, Privacy and Technology Project. I asked Ayesha to put the history of yellow fever in New Orleans into the context of our current COVID pandemic.

So an immunity passport or an immunity certificate system would be one where people have some sort of verified way of showing that they have immunity to COVID-19, and then presumably they would use this certificate or passport to work in certain areas for certain employers that are requiring this.

Back in the 19th century, there was no real way to verify someone's immunity to yellow fever. But with today's science and technology, Ayesha's concerned about how far-reaching a system like this could become.

You can imagine a variety of either government or private sector-driven app-based immunity passport or certificate systems. To my knowledge, we haven't seen anything like this before. It would also create a new class system. An immunity passport system would create a two-tier system because it would divide all of us into those who are immune to COVID-19 and those who are not. And the people who are immune will get all of the benefits and privileges that come with that, while everybody else who's not immune will be in a second-class status.

These pressures are already weighing on workers like those Juanita told us about at the top of the show.

I think that any system that incentivizes people to get a highly contagious and very dangerous disease, that's, that's bad for public health.

A system like this would disproportionately affect people of color. The pandemic has pushed unemployment rates for African Americans and Latinx workers to some of the highest on record.

We know that people are suffering economically. We know that there's a lot of hardship out there, and if people are told that they will get better access to jobs or perhaps higher wages if they have immunity, we can see the inevitable consequences of that. Some people will really try to get COVID-19 as the only way out of, you know, a dire economic circumstance, and I think the last thing that public health officials want to do right now, given the state of The worldwide pandemic, but especially in the United States, is incentivize more people to get COVID-19.

Any system that incentivizes people to get infected with COVID puts lives at risk. But again, people of color in the United States would face an even more perilous decision. These communities have higher than average rates of underlying conditions like hypertension and diabetes, which are risk factors for severe COVID disease.

A lot of these are disabilities, and so people with these preexisting conditions won't really be able to take the risk of getting COVID-19. It would be playing Russian roulette with your life. So you'll be putting people with disabilities in this very tough spot where they're unable to acquire immunity even if they have the same incentives because they're economically vulnerable, they need to be able to go out and work. But for them, the risks of contracting COVID-19 are even greater.

But wait, don't we already have a version of this? Lots of jobs require proof of vaccination or immunity. For example, restaurant workers have to get a hepatitis A vaccine before they can work. There's a whole slew of vaccinations I need to get as a doctor. Why would COVID be so different?

An immunity passport system is fundamentally different from a system requiring proof of vaccination because in the latter system, People are not being asked to get ill with a disease in order to access critical life opportunities like employment, like access to healthcare, like the ability to travel. So in this circumstance, the only way to have immunity is to get COVID-19. The concerns go well beyond the workplace. If you build a health surveillance infrastructure like this, its use will expand, and we've seen this with so many technologies in the past and with so many new databases that are created for one purpose. And then there's mission creep.

If you read George Orwell's classic novel, 1984, you'll get a preview of what Ayesha is describing.

Depending on how an immunity passport system is created, it's quite possible it could be centralized and hosted either by a handful of private companies or government agencies. And it's very concerning to us because If that information about people's health status is stored, particularly if it's stored with additional information like their employer or their travel history or their housing information, that this information could be abused.

And these systems may even end up counterproductive as public health measures. Some groups may avoid seeking healthcare, fearful of how that information could be used against them.

For example, immigrant communities might be very reluctant to give their information over to such a database because of the fears that it could be used against them. People might worry about consequences for them with their health insurance. Without airtight privacy protections, the system would be really vulnerable to abuse.

History is repeating itself. In 19th century New Orleans, public officials took the same approach as many are again today. Putting business and commercial prosperity over public health. Here's Katherine Olivarius again.

They had made the economy work without having to promote the public's health. So, you know, it's not their job to, you know, sort of provide the kind of public health infrastructure that would protect a person from the disease. In fact, it was their job to hasten that as much as possible. You know, our public health essentially is private acclimation. And there's a lesson in this.

Here's Ayesha again.

[Speaker:AYESHA] I think that history should be our guide here, and I think that the studies of what happened during the past yellow fever outbreaks are very instructive. We should be very concerned if rather than investing either private or public funds to ensure a universal public health response that involves testing that's accessible to all, that involves universal precautions that workplaces are required to take that protects all workers. If instead we move towards a system of immunity passports, that will lead to the exploitation of workers, that will lead to vulnerable workers being most likely to need to contract COVID-19 just to be able to live and work. It is a system that will harm the most vulnerable among us. It will have disproportionate impacts on people with disabilities. And workers of color, and it won't necessarily do anything to keep all of us safe. So I think that we really should be suspicious of any quick fix or easy solution like this instead of doing perhaps the harder work of ensuring universal worker protections that would apply to everybody.

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