Cholera To COVID-19, The 'Immunity Passport' Debate Is Back

Talk about the use of documents proving immunity evokes a measure invented more than a century ago by French authorities.

'COVID passports,' we are told, could facilitate travel and trade
"COVID passports," we are told, could facilitate travel and trade
Joëlle M. Abi-Rached*

PARIS — As governments strive to acquire vaccines against COVID-19 and launch vaccination campaigns in the midst of global uncertainty, a new idea seems to be gaining ground: an immunity passport.

These "COVID passports," we are told, could facilitate travel and trade. They would certify that a person has received a vaccine or has been infected by proving, for example, the presence of antibodies against the new virus.

This idea is not new. It stems from the passeport sanitaire, a 19th-century French invention (not without controversy) whose purpose was quite different. The holder of the health passport was considered "immune" in the medieval sense of the word (from the Latin immunis), i.e. "free" of symptoms until proven otherwise. Moreover, inoculation was not included on this document, whose purpose was rather to allow authorities to detect suspicious or reported cases, and consequently to extinguish any epidemic threat at French borders.

On June 18, 1890, in order to keep cholera —rampant at the time in Spain — from spreading in France, the Interior Ministry produced a memorandum asking prefects to issue travelers with a "health passport" and a "notification card" addressed to the relevant mayor. The mechanism consisted of having each traveler examined by a doctor and then reporting to the local authorities that the person had been "recognized as healthy" but had to remain "under medical supervision" during the incubation period. This health passport was, in addition to the "political passport," another French invention conceived in the 15th century initially to "pass' goods and quickly extended to people.

The WHO's "Yellow card" and a French Passport — Photo: Walid Berrazeg/SOPA Images via ZUMA Wire

It was during the 1893 International Sanitary Conference in Dresden that Adrien Proust — professor of health at the Paris Faculty of Medicine, chief physician at the Hôtel-Dieu and father of the novelist Marcel Proust — suggested that this procedure be used internationally. The Austro-Hungarian Empire had convened the conference in Dresden against a backdrop of cholera epidemics that were spreading more rapidly in Europe with the arrival of the steamboat. It was imperative to standardize international quarantine regulations against the spread of these new health threats.

For Adrien Proust, any epidemic was first controlled at the borders. He saw in the health passport a more targeted version of quarantine and the equivalent of "observation" at the lazaret (a quarantine location for sea voyagers). The health passport was thus a means of tracing people considered asymptomatic and isolating them in case they became symptomatic. The objective was to prevent "outbreaks' of infections, and this procedure made it possible to "act quickly and effectively" — before it was too late.

Preventive inoculation, on the other hand, was only possible for the plague, and was only recommended for those most at risk (such as personnel disinfecting ships). In addition, Proust considered inoculation to be less effective than strict "sanitary surveillance" for several reasons. First, it was not mandatory; second, it did not protect infected but asymptomatic people; and third, it induced only short-term immunity.

But the health passport was not without its critics. Not only did the British delegation not sign the agreement reached at the Dresden conference, but the whole idea of a health passport was rejected. The prestigious British medical journal The Lancet determined that these health passports were "useless' because they could be falsified and ineffective, as they required a human infrastructure that was disproportionate to their health performance.

Le Petit Journal front page from December 1912 — Photo: Bibliothèque nationale de France

"We can be certain that no such document will ever be required of people arriving in this country or in some of the most advanced countries on the continent," the journal concluded.

How to explain this rejection? Proust criticized the British "liberal" approach which — although restrictive on its own soil — was opposed to any measure likely to compromise international trade. For the chief physician of the Hôtel-Dieu, the British system was not to be copied. If the "bill of health," the equivalent of the "health patent," commonly used by sailors since at least the 17th century, was easier to administer, it was less effective from a health point of view.

Moreover, the laissez-faire approach to sanitation in the English colonies was detrimental. In 1896, it had led to the spread of the plague to India, where thousands of people died. The same can be said of the appearance of cholera in Egypt in 1883, 1805 and 1902, where the British colonial authorities had not put in place adequate sanitary measures.

Despite British reluctance, and with the advent of aviation from the 1930s onwards, the World Health Organization introduced an "international certificate of vaccination or prophylaxis." Now more commonly known as the "Yellow Card," it became compulsory, especially for travel to certain African countries where "endemic" diseases (such as yellow fever or malaria) are a danger not for the natives, who are forced to "live with" these scourges, but for travelers.

There's a big difference, nevertheless, between the yellow card and the so-called "COVID passport." The latter would grant immunity and freedom of movement in places considered "healthy," while the yellow card gave foreigners the right to travel in countries recognized as "unhealthy" — without, of course, bringing their "plagues' back to the metropolises of rich, developed and sterilized countries.

*Joëlle M. Abi-Rached is a physician by training, medical historian and associate researcher at the Medialab of Sciences Po, Paris. His latest book is Asfuriyyeh: A History of Madness, Modernity, and War in the Middle East (MIT Press, 2020).

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Where Lockdowns For LGBTQ Meant Moving Back In With Homophobic Relatives

The confinement experience could turn brutal for those forced to live with relatives who would not tolerate a member of the family living their sexual orientation openly as a young adult. Here are stories from urban and rural India.

At a Rainbow pride walk in Kolkata, India

Sreemanti Sengupta

Abhijith had been working as a radio jockey in the southern Indian city of Thiruvananthapuram when the COVID-19 pandemic hit in March, 2020. When the government imposed a nationwide lockdown, Abhijith returned to the rural Pathanamthitta district , where his parents live with an extended family, including uncles, cousins and grandparents.

Eighteen months later, he recalled that the experience was "unbearable" because he had to live with homophobic relatives. "Apart from the frequent reference to my sexual 'abnormality', they took me to a guruji to 'cure' me," Abhijith recalled. "He gave me something to eat, which made me throw up. The guru assured me that I was throwing up whatever 'demon' was possessing me and 'making' me gay."

Early in 2021, Abhijith travelled back to Thiruvananthapuram, where he found support from the members of the queer collective.

Inspired by their work, he also decided to work towards uplifting the queer community. "I wish no one else goes through the mental trauma I have endured," said Abhijit.

Abhijith's story of mental distress arising from family abuse turns out to be all too common among members of India's LGBTQ+ community, many of whom were trapped in their homes and removed from peer support groups during the pandemic.

Oppressive home situations

As India continues to reel from a pandemic that has claimed more lives (235,524) in three months of the second wave (April-June 2021) than in the one year before that (162,960 deaths in March 2020-March 2021), the LGBTQ community has faced myriad problems. Sexual minorities have historically suffered from mainstream prejudice and the pandemic has aggravated socio-economic inequalities, instigated family and institutionalized abuse, apart from limiting access to essential care. This has resulted in acute mental distress which has overwhelmed queer support infrastructure across the country.

Speaking to queer collective representatives across India, I learned that the heightened levels of distress in the community was due to longstanding factors that were triggered under lockdown conditions. Family members who are intolerant of marginalized sexual identities, often tagging their orientation as a "disorder" or "just a phase", have always featured among the main perpetrators of subtle and overt forms of violence towards queer, trans and homosexual people.

Calls from lesbians and trans men to prevent forced marriages during lockdowns.

Sappho For Equality, a Kolkata-based feminist organization that works for the rights of sexually marginalized women and trans men, recorded a similar trend. Early in the first wave, the organization realized that the existing helpline number was getting overwhelmed with distress calls. It added a second helpline number. The comparative figures indicate a 13-fold jump in numbers: from 290 calls in April 2019-March 20 to 3,940 calls in April 2020-May 2021.

"Most of the calls we have been getting from lesbians and trans men are urgent appeals to prevent forced marriages during lockdowns," said Shreosi, a Sappho member and peer support provider. "If they happen to resist, they are either evicted or forced to flee home. But where to house them? There aren't so many shelters, and ours is at full capacity."

Shreosi says that the nature of distress calls has also changed. "Earlier people would call in for long-term help, such as professional mental health support. But during the pandemic, it has changed to immediate requests to rescue from oppressive home situations. Often, they will speak in whispers so that the parents can't hear."

Lack of spaces

Like many of his fellow queer community members, life for Sumit P., a 30-year-old gay man from Mumbai, has taken a turn for the worse. The lockdown has led to the loss of safe spaces and prolonged residence at home.

"It has been a really difficult time since the beginning of the lockdown. I am suffering from a lot of mental stress since I cannot freely express myself at home. Even while making a call, I have to check my surroundings to see if anybody is there. If I try to go out, my family demands an explanation. I feel suffocated," he said.

The pandemic has forced some queer people to come out

Sumit is also dealing with a risk that has hit the community harder than others – unemployment and income shortage. He's opened a cafe with two other queer friends, which is now running into losses. For others, pandemic-induced job losses have forced queer persons from all over the country to return to their home states and move in with their families who've turned abusive during this long period of confinement.

Lockdowns force coming out

According to Kolkata-based physician, filmmaker and gay rights activist Tirthankar Guha Thakurata, the pandemic has forced some queer people to come out, succumbing to rising discomfort and pressure exerted by homophobic families.

"In most cases, family relations sour when a person reveals their identity. But many do not flee home. They find a breathing space or 'space out' in their workspaces. In the absence of these spaces, mental problems rose significantly," he said.

Not being able to express themselves freely in front of parents who are hostile, intolerant and often address transgender persons by their deadname or misgender them has created situations of severe distress, suicidal thoughts and self-harm.

Psychiatrist and queer feminist activist Ranjita Biswas (she/they) cites an incident. A gender-nonconforming person died under suspicious circumstances just days after leaving their peer group and going home to their birth parents. The final rites were performed with them dressed in bangles and a saree.

"When a member of our community asked their mother why she chose a saree for someone who had worn androgynous clothes all their life, she plainly said it was natural because after all, the deceased 'was her daughter,'" Biswas recalls.

The Indian queer mental health support infrastructure, already compromised with historical prejudice, is now struggling

David Talukdar/ZUMA

"Correctional" therapy

In India, queer people's access to professional mental healthcare has been "very limited," according to community members such as Ankan Biswas, India's first transgender lawyer who has been working with the Human Rights Law Network in West Bengal.

"A large majority of the psychiatrists still consider homosexuality as a disorder and practice 'correctional therapy'. It's only around the big cities that some queer-friendly psychiatrists can be found," Biswas said. "The pandemic has further widened the inequalities in access to mental health support for India's LGBTQ community."

Biswas is spending anxious days fielding an overwhelming amount of calls and rescue requests from queer members trapped in their homes, undergoing mental, verbal and even physical torture. "We don't have the space, I just tell them to wait and bear it a little longer," he said.

Medical care is dismal

Anuradha Krishnan's story, though not involving birth family, outlines how the lack of physical support spaces have affected India's queer population. Abandoned by her birth family when she came out to them as a trans woman in 2017, Anuradha Krishnan (she/they), founder of Queerythm in Kerala who is studying dentistry, had to move into an accommodation with four other persons.

Isolation triggered my depression

"I am used to talking and hanging around with friends. Isolation triggered my depression and I had to seek psychiatric help." Living in cramped quarters did not help with quarantine requirements and all of them tested positive during the first wave.

What is deeply worrying is that the Indian queer mental health support infrastructure, already compromised with historical prejudice, is now struggling, placing more and more pressure on queer collectives and peer support groups whose resources are wearing thin.

During the 10 months of the first wave of the pandemic in India in 2020, Y'all, a queer collective based in Manipur, received about 1,000 distress calls on their helpline number from LGBTQ+ individuals. In May 2021 alone, they received 450 such calls (including texts and WhatsApp messages) indicating a telling escalation in the number of queer people seeking help during the second wave.

As India's queer-friendly mental health support infrastructure continues to be tested, Y'all founder, Sadam Hanjabam, a gay man, says, "Honestly, we are struggling to handle such a large number of calls, it is so overwhelming. We are also dealing with our own anxieties. We are burning out."

Sreemanti Sengupta is a freelance writer, poet, and media studies lecturer based in Kolkata.

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