Challenges of balancing international health and travel in a pandemic: Lessons from the French Caribbean during COVID-19 passports

The travel and tourism sector benefited greatly from the relaxation of restrictions during the pandemic, yet its impact on health systems remains inadequately addressed.¹ This is partly because of conflicts of interest over the COVID-19 vaccine policies.^2,3

The vaccine is approved by the World Health Organization (WHO) to serve as a health instrument, i.e., to protect against hospitalisation, severe disease, and death at the individual level. While providing individual benefits, available vaccines have not been able to prevent transmission,² and therefore COVID-19 vaccination is not recommended by WHO as a laissez-passer for international travel restrictions.⁴ However, vaccine passports were pushed onto the international agenda by the World Tourism Organization (UNWTO) in the wake of the marketing authorisation of COVID-19 vaccines, when “recognizing the urgent need to restart tourism in view of the summer tourist season in the Northern Hemisphere” in May 2021⁵ – i.e., to deregulate travel-related control measures, irrespective of the emergence of the delta variants.¹

In our opinion, travel-related control measures can make up a safety net against destructive outbreaks in travelled places equipped with fragile health systems.⁶ Contrary to the policy that France currently applies in the French Caribbean, travel-related control measures should not discriminate against people, especially not the children and pregnant women, neither based on their nationality nor on their COVID-19 vaccination or recovery status.² Travel-related control measures have both benefits and harms for island communities with one harm being rebound epidemics when borders reopen prematurely. COVID-19 outbreaks are temporary in nature but are currently cadenced by holiday seasons in the French Caribbean.¹ Lifting travel-related control measures should always account for the local context in a pandemic, which encompasses real-world ethical considerations and scientific evidence⁴ from cross-sectoral routine surveillance.¹

Summer holidays 2022 began with Paris lifting the testing requirements for COVID-19 recovered and vaccinated travellers, in parallel with French Caribbean university hospitals (re)activating their emergency response plans (i.e., the French “Plan blanc”) for COVID-19, which revives fears of patient triage. Summer is an all-hazards season in the Caribbean (i.e., hurricanes and epidemics), and health systems should not go it alone.

Last year, in June 2021, France adopted the “vaccine passport” for the first time to the French Caribbean for waiving travel-related control measures, two months before mandatory COVID-19 vaccination was extended to mainland France for long-distance travel. Only 16% of the French Caribbean population received their first dose of the vaccine upon the implementation of this “travel bubble” policy.¹

At the time, the lifting of travel restrictions based on vaccine passports to restart mass tourism created a perfect storm in the French Caribbean, resulting in destructive epidemics and hospital capacities becoming at once overwhelmed and dependent on external medical aid. The health outcome was France's highest regional record of 6-month all-cause excess mortality in the past 70 years.¹

Inevitably, COVID-19 vaccines became politicised, bolstering anti-vaccination movements and the feeling amongst the population that they were being bullied. Faced with a perceived do-or-die situation, hospital workers and the population at large, soon opposed the COVID-19 vaccine mandate resulting in major civil unrest.¹

It should not be surprising that French Caribbeans are hesitant to accept COVID-19 vaccines because of low baseline levels of confidence that their interests would be prioritised by institutions in France and the European Union (EU). Among other recent experiences, the scandal of chlordecone - a large-scale agrochemical pollution condoned to export bananas into the European market - that rendered most French Caribbean local farming, fish stocks, and water sources unsuitable for human consumption, damaged the image of French and EU institutions.⁷

Travel and tourism are highly subsidised industries and at the forefront of COVID-19 recovery strategies in territories that are overdependent on them:⁸ the French government glossed over the fact that the vaccine passport does not prevent transmission and the European Commission continues to arouse interest for French Caribbean mass tourism.^1,9

France has long had little regard for health system building blocks in the French Caribbean.¹⁰ The French Caribbean territories are made up by tiny islands, administrated by local elites mostly parachuted from Paris, who enjoy privileged revenues alongside widespread precarity in the Caribbean population at large. This relative deficit of local leadership makes it difficult for French Caribbean islanders to voice their opinion beyond their shores, back to Paris or Brussels, to the corridors where major political decisions concerning their fate are being made. There is a structural disregard for the French Caribbean in assessments of health policies and publications in the literature,¹⁰ and beating the regional records of France's COVID-19 mortality rates has made no exception.¹

Subsidised travel and tourism corporations are no representation of the French Caribbean population, which remains disproportionally un(der)employed since decades. All in all, the local economy lacks diversification.^9,11 More than one French Caribbean in four was unemployed in 2014 (i.e., three times more than in mainland France). Subsequently, overemployment in the French Caribbean hospital sector buffers the lack of employment in the population at large, adding structural weaknesses in health system governance and performance.¹⁰

Finally, the representation deficit in the French political system is a breeding ground for the independence movement and may explain the extreme volatility of voter behaviour at the French presidential elections in the French Caribbean. The region features France's highest drop of final votes for the winning candidate Emmanuel Macron, from more than 75% in 2017 to 30–40% in 2022.

Faced with these challenges, a caring government needs to rethink COVID-19 resilience in line with epidemiological evidence¹ as well as the views of minorities and marginalised groups.²

Thinking the present and future of small island tourism economies requires state and non-state actors to remove policy biases unduly favouring tourism and travel relative to the control of infectious disease risks: realigning state regulations and subsidies with the objective of health for all,⁸ and empowering the population at large with pandemic literacy are the top priorities.1, 2, 3

There is no miracle cure and no quick fix solution for all social and economic issues exposed by the COVID-19 crisis – it is a syndemic.¹² The COVID-19 vaccine does exactly what it says on the tin: it is but one public health intervention, which comes with risks and benefits, and provides individual benefits but cannot prevent epidemics.² It is time for disambiguating COVID-19 recovery strategies in order to balance priorities in a pandemic and transform high-risk industries.¹ The modus vivendi between interconnected communities in the era of pandemic risks should be based on health for all — which entails a fair access to political voice and economic opportunities, for all.

Contributors

EJ and SA contributed to the conceptualisation.

SA contributed to the administration and the writing of the original draft.

DK, EM and SA contributed to the supervision.

DK, EJ, EM, and SA contributed to the validation, reviewing and edition.

Declaration of interests

EJ declares a conflict of interest with a grant intended for his institution (Wellcome) and consultancy fees for report writing (Democ. Fund). EM, DK and SA declare no conflict of interest.