Introduction

In January 2021, Dr. Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization (WHO), described the hoarding of COVID-19 vaccines by wealthy nations as a “catastrophic moral failure” that would “only prolong the pandemic, the restrictions needed to contain it, and human and economic suffering” [1]. Yet despite repeated calls for an equitable, globally coordinated approach to COVID-19 vaccination, vaccine apartheid has been unaddressed; as of March 2021, 78% of the 447 million doses were deployed in just ten countries [2]. By August 2021, over half of all people were fully vaccinated in Canada, the United States, the United Kingdom, and other Western countries, compared with just 11% in Latin America and the Caribbean [3–6]. These gross disparities are poised to deepen as third and fourth doses are increasingly recommended by governments and public health officials across North America and Europe [7]. Within countries already at the end of the line for doses, marginalized communities face additional barriers to access COVID-19 vaccines [8]. On both a global and a national scale, policymakers are grappling with how to prioritize COVID-19 vaccination to slow pandemic spread and protect the most vulnerable, including migrants.

Greater attention to migration status as a determinant of COVID-19 vaccine equity is urgently needed. Irregular migration status often intersects with experiences of “racism, patriarchy, economic disadvantages, and other discriminatory systems…to create layers of inequality” [9]. In 2000 the Committee on Economic, Cultural, and Social Rights (CESR) affirmed that “States are under the obligation to respect the right to health by, inter alia, refraining from denying or limiting equal access for all persons, including prisoners or detainees, minorities, asylum seekers and illegal immigrants, to preventive, curative and palliative health services” [10]. Yet, some restrictions of rights based on irregular migration status may be justified; for example, the International Convention of Migrant Workers (ICMW) reduces the right to health for migrants in an irregular situation to “medical care that is urgently required for the preservation of life or the avoidance of irreparable harm to their health” [11]. The CESR further specified that irregular migrants are to be considered ‘specifically vulnerable’ people, recalling the New York Declaration for Refugees and Migrants which “reaffirmed the human rights of all refugees and migrants, regardless of status” [12]. In March 2020, the United Nations further stipulated that when a vaccine for COVID-19 became available, it should be provided “without discrimination”, that resource scarcities “should never be used as a justification to discriminate against certain groups of patients”, and that a human rights approach is effective in preventing “major public health threats” [14].

Yet, COVID-19 vaccine access has repeatedly been denied to migrants, particularly those with irregular migration status, referring to migrants who entered a country without authorization or required documentation and often lack access to basic rights, including health care [13, 14]. By May 2022, out of 180 countries evaluated globally by the United Nations International Organization for Migration, 39 countries excluded migrants with an irregular status from COVID-19 vaccination plans, underscoring the precarity of irregular migrants produced in part through state-supported exclusion from social protections [15]. Exclusion from COVID-19 vaccination efforts based on migration status raises important concerns surrounding State protections and the health rights of migrants in an irregular status amid public health emergencies.

By August 2022, more than 6.8 million Venezuelans fled the country due to political, economic, and social turmoil, making it the largest international displacement in Latin America and the Caribbean in contemporary history [16]. Most Venezuelans remain in South America, placing severe socioeconomic strains on countries such as Argentina, Brazil, Chile, Colombia, Ecuador, and Peru, which collectively host over 5.1 million Venezuelans [17]. While both regular and irregular migrants face stigmatization, discrimination, and health care access barriers, lack of documentation can make these issues particularly salient for irregular migrants. For many countries, government-issued identification documents (IDs) are required to access COVID-19 vaccinations. ID requirements coupled with heightened xenophobia and ongoing human rights violations may negatively impact how Venezuelan migrants are included in host country vaccination policies [18].

While the Latin American region has been significantly impacted by Venezuelan mass migration, limited research has assessed the sociopolitical climates shaping COVID-19 vaccine access for displaced Venezuelans. Thus, there is an urgent need to understand how rising numbers of displaced Venezuelans will be addressed in country-level COVID-19 vaccination policies. Addressing this gap, between April and June 2021, we examined the bioethical and human rights dimensions of country-level COVID-19 vaccination policies for migrants. This research builds on existing work linking health inequities to societal and structural-level forces, such as racism, capitalism, power, and politics [19–21]. In doing so, we theorize health as inextricably linked to not just individual-level decisions or community factors, but also broader societal forces. While results are inherently limited by the timeframe of our search, we aim to better understand migration status (i.e. regular and irregular) as a dimension of vaccine equity through country-level vaccination plans and in relation to international human rights obligations and the “WHO SAGE values framework for the allocation and prioritization of COVID-19 vaccines”, which provides guidelines to promote equity within global and national prioritization of vaccination.

COVID-19 vaccination facilities and equity frameworks

In recognition of underlining inequities pervasive in emergency vaccine administration, the “WHO SAGE values framework for the allocation and prioritization of COVID-19 vaccines” (hereafter referred to as the WHO/SAGE framework) was developed “for COVID-19 vaccines to contribute significantly to the equitable protection and promotion of human well-being among all people of the world” [22]. The WHO/SAGE framework is guided by a bioethical approach emphasizing that social vulnerabilities (including citizenship status) should be considered when prioritizing COVID-19 vaccination. However, as Sekalala and colleagues note, while the WHO/SAGE framework mentions human rights principles and references State obligations to promote ‘global equity’, it falls short of human rights obligations to hold States accountable to ensure equity in access to vaccines [23].

Second, the need for international collaboration led to the creation of COVID-19 Vaccines Global Access (COVAX) to support vaccine research and development and promote global equity in vaccine distribution [24]. COVAX contains a small “humanitarian buffer” (around 5 percent of doses), which includes doses for migrants and refugees who otherwise do not have access through national vaccination campaigns. Yet, the number of doses available through COVAX is wholly inadequate given the magnitude of the Venezuelan migration crisis and other migration crises [25]. COVAX does not specify how national prioritization of vaccination should proceed, leaving governments to define priority groups for COVID-19 vaccination.

Existing COVID-19 vaccination facilities and equity frameworks may not adequately account for the unique vulnerabilities facing migrants amid COVID-19. For example, the WHO/SAGE framework, which is meant to guide State actors, lacks accountability in upholding the health rights of non-citizens. Scholars have thus argued that COVID-19 vaccination frameworks can be strengthened by aligning with international human rights obligations that define health rights; this can create legally enforceable frameworks that can be used to hold States accountable for protecting rights, particularly amid emergencies such as COVID-19 [23]. Indeed, international human rights treaties (including the International Covenant on Civil and Political Rights and the International Covenant on Economic, Social, and Cultural Rights) are ratified and legally binding in most countries globally. While the ICMW only guarantees access to emergency lifesaving emergency medical care, the United Nations CESR has emphasized that access to COVID-19 vaccines is “an essential component of the right of everyone to the enjoyment of the highest attainable standard of physical and mental health and the right of everyone to enjoy the benefits of scientific progress and its applications” [26]. The Committee also underscores the obligation of States “as a matter of priority and to the maximum of their available resources, to guarantee all persons access to vaccines against COVID-19, without any discrimination” [26]. The integration of human rights into existing vaccination frameworks would transform ethical imperatives into obligations and rights, which can be mobilized in legal and political strategies by civil society and social actors to hold States accountable for ensuring health rights are fulfilled [23].

Methods

Results

Across the analysis, three key rights-related concerns were found to restrict the right to health for migrants in Latin America amid COVID-19: 1) lack of prioritization of migrants in vaccine distribution; 2) onerous documentation requirements to be eligible for COVID-19 vaccination; and 3) how pervasive anti-migrant discrimination limited equitable health care access. A detailed analysis of country-level vaccination plans, phases of vaccination, and ID requirements for vaccination is presented in Table 1, and Fig 1, in the Discussion, provides recommendations based on results for integrating human rights into existing COVID-19 vaccination facilities and frameworks (i.e. WHO SAGE/values).

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Fig 1. Integrating human rights into a modified WHO/SAGE framework to address the unmet COVID-19 needs of migrants.

Inner circle: Summary of select principles in the WHO/SAGE framework. Outer circle: Integrating human rights with WHO/SAGE to promote equitable access to COVID-19 vaccines for migrants.

https://doi.org/10.1371/journal.pgph.0001275.g001

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Table 1. Phases of COVID-19 vaccination, ID requirements, and inclusion of Venezuelan migrants in six host countries as of June 2021.

https://doi.org/10.1371/journal.pgph.0001275.t001

Discussion

These findings advance understandings of migration status as a determinant of COVID-19 vaccine equity by presenting a regional analysis of how country-level COVID-19 vaccination policies in Latin America facilitate access for migrants and displaced people. While the scale and impact of Venezuelan mass migration were underscored in the peer-reviewed and gray literature reviewed, government plans and policies highlighted that States’ provided limited safeguards for non-citizens with precarious or irregular status. Our results underscore the imperative to not only recognize but also address protections for non-citizens in Latin America. International human rights principles reinforce the obligations of States to ensure equity for all in access to COVID-19 vaccines, regardless of citizenship or migration status.

The potential impact of our results not only help underscore how existing gaps in COVID-19 vaccination could have been addressed by human rights approaches, but also advance understandings of how future public health interventions can better integrate human rights principles to complement strategies informed by epidemiological risk. Existing and pervasive disparities highlight how COVID-19 vaccines, no matter how effective at preventing infection or severe illness, cannot reach their full promise without the integration of context-specific sociopolitical factors in their rollout. Human rights-related concerns surrounding COVID-19 vaccine access for displaced Venezuelans include: lack of prioritization of migrants in vaccine distribution; onerous documentation requirements to be eligible for COVID-19 vaccination; and how pervasive anti-migrant discrimination limited equitable health care access. These findings align with reports from the United Nations International Organization for Migration and WHO that country-level vaccination plans often lack clarity regarding the inclusion of migrants and fail to address underlying health care access barriers, particularly for migrants with irregular status [54].

This research builds on existing literature urging the integration of human rights perspectives in responses to COVID-19 to ensure health equity for migrants [54]. We have identified key priorities when designing and implementing COVID-19 vaccination plans to ensure equity for migrants and/or displaced people in the Latin American region. Paralleling literature detailing the urgency of incorporating human rights perspectives into vaccine deployment, planning and coordination mechanisms must account for non-citizens, particularly those with irregular migration status [54]. More broadly, mechanisms need to be adopted to address pervasive discrimination and ensure secure and safe access to public health systems for migrants. Assessment of priority groups within country-level vaccination policies alongside gray and peer-reviewed literature allows for an examination of how governments initially conceptualized access to vaccines for migrants and mobile populations amid a pandemic. Fig 1 situates five of the principles guiding the allocation and prioritization of COVID-19 vaccination as described by the WHO/SAGE framework alongside recommendations for how existing gaps could have been addressed through the integration of human rights.

Recommendations based on this review build on the WHO/SAGE framework which outlines six principles guiding COVID-19 vaccine prioritization, and underscores how social vulnerabilities (including migration status) should inform national vaccination policies. These include: (1) human wellbeing; (2) equal respect; (3) global equity; (4) national equity; (5) reciprocity; and (6) legitimacy. The WHO/SAGE framework calls for migrants to be prioritized in COVID-19 vaccination plans given their increased social vulnerabilities and existing barriers in accessing health services. For example, the principle of “national equity” advocates for the prioritization of vulnerable communities, such as people living in poverty, refugees, and internally displaced persons, those affected by humanitarian emergencies, and irregular migrants. Recognizing their increased risk of COVID-19 acquisition and severe illness, the WHO/SAGE framework underscores why migrants should be named as priority groups for COVID-19 vaccination. Yet, as evidenced in our review, scant attention was paid to accountability in implementation of country-level vaccination plans, resulting in States prioritizing the vaccination of citizens over non-citizens.

Fig 1 builds on a modified WHO/SAGE Framework to present how COVID-19 vaccine allocation and prioritization can better consider the health rights of migrants and non-citizens. For example, while the existing WHO/SAGE framework suggests that all people should be treated with equal respect, human rights obligations hold States accountable for ensuring dignity and equal respect for all. Similarly, while the WHO calls for “a transparent consultation process” in decisions surrounding COVID-19 vaccine policies, a rights-based approach necessitates that made-vulnerable communities participate actively in decision-making processes. Finally, extraterritorial obligations underscore the responsibility of States to uphold the health rights of all people, not just those residing within their national borders. Reciprocity is a principle of narrower scope compared to the other five as it specifically addresses those within society “who bear substantial additional risks and burdens of COVID-19 response for the benefit of society” [22]. While many migrants are trained as health care workers and/or first responders, they are often unable to work in these fields given challenges with documentation, and thus do not qualify under this principle. Assessment of policies related to whether migrants and other displaced people can provide COVID-19 care irrelevant of documents was outside of the scope of our review, and thus reciprocity is not presented in Fig 1. Nonetheless, future research is needed to better understand how the principle of reciprocity can be interpreted and applied to migrants and other displaced people, especially given known shortages of healthcare workers in the Latin American region [55].

While the WHO/SAGE framework underscores the need to consider social vulnerabilities, our review revealed that country-level vaccination plans rarely accounted for the structural inequities driving increased exposure to COVID-19 for marginalized communities. These findings support literature evidencing how unstable housing, precarious employment, discrimination, and health care access barriers represent intersectional structural-level factors that constrain access to social protections not only for migrants, but also for other marginalized groups [56]. Prioritizing vaccination based solely on epidemiological risk groups serves to individualize risk and invisibilize the structural-level factors that produce group vulnerabilities. As argued by Sekalala and colleagues, “international human rights law requires that ‘vulnerability’, if used as a criterion for priority access to COVID-19 vaccines, must include social vulnerability (e.g. socioeconomic status) in addition to medical vulnerability (e.g. comorbidities), and attend to intersectionalities” [23]. In this way, prioritization of COVID-19 vaccination must be informed not only by epidemiological risk of morbidity and mortality; a human rights perspective would also require social vulnerabilities be considered when defining vaccine priority groups. As shown by Freier et al., this position has been adopted by the Inter-American Commission on Human Rights and the Inter-American Court of Human Rights, who established that the human rights principles of equality and non-discrimination requires States to not only prohibit discrimination based on migration status, but also to take special measures to address and reverse structural and systemic discrimination, exclusion, and vulnerability faced by migrants [57]. In countries where migrants already faced high rates of discrimination, xenophobia, criminalization, poverty, exploitation, and violence, COVID-19 exacerbated inequities in employment, health, and access to social services [58].

Findings underscore that sustained attention must be paid to the structural inequities described above that are not new, but rather pervasive consequences of neoliberal globalization. This call to center vulnerability seeks to underscore the broader systemic oppressions that make certain communities in Latin America particularly vulnerable to COVID-19 and other epidemics. It demands attention to be paid to imperialist structural adjustment policies that have left public health systems underfunded and ill-equipped to deal simultaneously with mass migration and a pandemic. Indeed, in response to the emerging debt crisis in the 1980s, countries across Latin America accepted loans from the World Bank and International Monetary Fund; conditions of these loans included mandates to privatize state assets, cut government spending, devalue currencies, and liberalize trade [59]. These large-scale cuts to government spending on social services widened health inequities as health care became increasingly unaffordable for the most vulnerable, including migrants [59]. The prioritization of COVID-19 vaccines in Latin America must be situated within ongoing neoliberal reforms yielding chronically underfunded social systems, including health care [60]. In sum, COVID-19 has repeatedly revealed the porousness of borders, yet responses continue to neglect the globalized and interconnected nature of the pandemic.

Caution should be observed in the interpretation of these results as findings are inherently limited by dynamic changes in approaches to COVID-19 vaccination that have occurred since this scoping review was conducted between April and June 2021. Review of country-level vaccination plans revealed at times daily shifts in vaccine prioritization and allocation, as well as migrants’ eligibility for vaccination, underscoring how rights claims were contested, mediated, and resolved across the study period. Indeed, in October of 2021, Colombia extended COVID-19 vaccine access to migrants with irregular status, including those without documentation [61]. While this policy change underscores how our findings must be understood within the context of initial vaccination efforts, there are important and lasting implications of these initial responses which merit further investigation. That said, given the scope of our three-month data collection period, it was not possible to fully assess how COVID-19 vaccination policies shifted across time. Additionally, vaccination data published across Ministry of Health websites did not disaggregate based on migration status, so the effects of COVID-19 vaccination policies on access to vaccines in practice could not be assessed. Further attention is also needed to the phases of vaccination, as well as definition of priority groups across different settings, not only in initial doses, but in the administration of booster doses also. Nonetheless, this review underscores ongoing gaps in COVID-19 vaccination plans as well as the crucial need to uphold international human rights obligations and consider the unique social vulnerabilities of displaced Venezuelans. As Peru and Brazil have done for Indigenous communities, this could be accomplished through an approach to vaccination that considers not just individual-level risk factors but also intersectional, structural-level factors that place displaced Venezuelans at increased risk for COVID-19. The application of a rights-based approach also highlights key tensions surrounding accountability for upholding the health rights for migrants and non-citizens, who can fall through the cracks of social protections amid intersecting crises such as COVID-19 and Venezuelan mass migration. Ensuring equitable access to COVID-19 vaccines is thus a first—and an essential—step to respond to COVID-19 more equitably and prepare for future public health crises in the context of displaced populations.

Conclusion

Amid rapidly evolving COVID-19 vaccination plans, findings presented here highlight how anti-migrant discrimination can be reinforced by governments and health systems when the human rights of migrants are not accounted for in vaccination policies across Latin America. A human rights approach provides a framework to advance global public health through legally binding international treaties and soft-law materials which transform moral imperatives into legal entitlements [23]. Countries across the region prioritized the allocation of limited vaccines to ‘at-risk’ groups as defined by countries and guided by primarily epidemiological factors (age, occupation, co-morbidities, etc.). Limited attention to social vulnerabilities (such as housing instability, economic precarity) and global forces driving the migration crisis (such as imperialism and neoliberalism) has exacerbated deep-rooted structural inequities faced by those abandoned by social safety nets, such as migrants. Keen attention and deeper inquiry are needed to the unique barriers faced by Venezuelan migrants with irregular status, defined as those who entered a country without the necessary authorization or documentation. Requirements for identification and other government-issued documentation to access vaccines creates critical access barriers (e.g. fear of deportation and xenophobic harassment, lost/expired documents), particularly for migrants with irregular status. Meanwhile, issues of cost, lack of familiarity with health care systems, and stigma and discrimination are intersectional issues that may be more salient among irregular migrants, particularly amid COVID-19 and future pandemics [62]. Stigmatization and scapegoating can result in discriminatory policies that further limit the ability of migrants to achieve the “highest attainable standard of health”.

The integration of human rights, rooted in legally binding treaties that can be used in litigation and advocacy, as well as soft law materials, into public health responses is a key strategy to improve accountability within implementation and uphold the health rights of marginalized and made-vulnerable communities. While this research predominantly analyzed country-level vaccination plans, these are just one component of multi-level vaccination strategies, which often involved provincial, municipal, or local-level governments also. To ensure health equity for migrants and displaced people, future COVID-19 vaccination strategies in Latin America must be informed not just by epidemiological approaches, but also by international human rights.