The US worried about vaccine tourists. Now it’s encouraging them.

Like many vaccine tourists, Alex" doesn't want you to know his real name.

The British expat arrived on a red-eye flight from his home in Nairobi, Kenya, at New York's John F. Kennedy International Airport on Friday, May 21, with the intention of staying just a few days-more than enough time, he hoped, to get a dose of the Johnson & Johnson vaccine.

Alex had been thinking about how to get vaccinated for weeks. Kenya has received only enough donated doses to vaccinate roughly 1% of its population, and while he would be eligible in the United Kingdom, getting shots there would be very complicated: a 14-day quarantine in a designated hotel upon arrival, registration with a local doctor, another 14-day quarantine upon his return to Kenya, and then likely a repeat of the whole process three or four months later for a second shot, since the one-dose Johnson & Johnson vaccine has not yet been approved in the UK.

The US, on the other hand, has no quarantine requirements and its vaccine supply has outstripped demand since April. After hearing first that a British couple he was friends with had successfully gotten their shot in Colorado, and then that New York City had plans to vaccinate travelers at popular tourist sites, Alex applied for his visa and booked his flight.

He doesn't feel great about it, though. The past few years of US politics have left the country low on his list of places to visit, and it doesn't make sense to him that he has to travel for a vaccine.

It's a bit of a joke, really," he told me before his trip. Is it really better to fly loads of people to New York to do this than to just fly some vaccines from New York to places where vaccines are needed?"

Opportunity for some

Almost as soon as the world's first covid-19 vaccine became available, there were reports of people working the system to get the shot ahead of their turn.

In the UK, some paid upwards of 40,000 ($56,000) to fly to the United Arab Emirates on luxury vaccine vacations. In the US, some traveled across state lines to take advantage of more permissive eligibility criteria in neighboring states. Others just drove from wealthier neighborhoods to poorer ones, armed with access codes meant to help immunize more people from marginalized communities heavily affected by the disease. This wasn't always called vaccine tourism, but it drew outrage, and no small amount of envy.

But as the vaccines have become more widely available in wealthy nations, the profile of vaccine tourists has also begun to shift-and so have government responses. A small but increasing number of places even see this travel as a way to help restart local economies stalled by the pandemic.

Such is the case with New York City.

In early-May, Mayor Bill de Blasio announced a proposal to offer visitors the J&J vaccine at popular tourist sites such as Central Park and Times Square. Come here; it's safe," he said in a press conference. New York is a great place to be," he added, and we're going to take care of you. We're going to make sure you get vaccinated while you're here with us."

That plan is currently pending approval from the state health department, but if Alex is any indication, de Blasio's message to tourists is already working.

And it's not just New York. Twenty-four states currently do not require residency for vaccines; 25 more offer the shot to both residents and nonresident workers.

Many have become destinations for foreign vaccine tourists. There are reports of Mexican celebrities flying into Miami, a Peruvian presidential candidate getting vaccinated in Texas, and Canadians seeking vaccines in American pharmacies just south of the border. At one point, the state of Florida became so concerned about foreign visitors taking advantage of its vaccine availability that it began requiring proof of residency at vaccination sites. (Florida ended the residency requirement in late April.)

Other states and territories have been more direct in tying vaccine tourism to their own economic recovery efforts. Alaska will begin offering the Moderna and Pfizer vaccines to visitors upon arrival at four airports on June 1, and the US Virgin Islands, while not explicitly marketing themselves as a vaccine tourism destination, have seen the benefits nonetheless.

This checks a lot of boxes for us," tourism commissioner Joseph Boschulte told Travel Weekly in April. Our economy benefits from those who stay several weeks, eat in our restaurants, stay at hotels, charter boats for day trips, and shop while waiting for the second shot. The airlines get the passengers who return a second time, and our visitor numbers increase. Our airlift right now is ahead of both the pre-pandemic lift and the pre-2017 hurricane flight operations."

A huge disconnect"

Despite the positive vaccine outlook in the United States, global vaccine distribution remains highly inequitable. According to one estimate by the Economist Intelligence Unit, 85 low-income countries will not have enough access to vaccines to cover 60% to 70% of the population until 2023. In the US, meanwhile, the Biden administration has set the arbitrary but symbolic deadline of reaching 70% of the population with at least one shot by July 4.

There's a huge disconnect growing where in some countries with the highest vaccination rates, there appears to be a mindset that the pandemic is over, while others are experiencing huge waves of infection," Tedros Adhanom Ghebreyesus, the director-general of the World Health Organization, said in a mid-May briefing.

And that vaccine gap is growing. COVAX, an international initiative to distribute covid-19 vaccines equitably, had secured commitments from manufacturers and wealthier donor nations for 2 billion doses to deliver to low-income countries by 2021. But the situation on the ground lags far behind those commitments: by the end of May, COVAX will have distributed only 65 million doses, far fewer even than its intended May goal of 170 million, and Unicef predicts that the initiative will have a shortfall of 190 million doses by the end of June. This is due primarily to production and distribution delays in India, a global vaccine production hub in the midst of a devastating second covid wave that has left at least 23 million infected and 250,000 dead.

A few days after Tedros's press conference, in response to mounting international pressure, the Biden administration pledged 20 million doses from its stash of Pfizer-BioNTech, Moderna, and Johnson & Johnson vaccines to COVAX. This represented a significant shift in policy: it was the first time the US was donating doses that could have been used domestically. (The administration has also committed to donate 60 million doses of AstraZeneca to COVAX but has yet to do so.)

Glenn Cohen, a law professor who directs Harvard Law School's Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics, says that the pledge of 20 million doses is a good first step" for a country that cannot get enough of its own people to use up its vaccine supply quickly enough.

But, he adds, it does not negate the ethical murkiness of having American cities and states offer, or consider offering, vaccines to visitors as official policy. Cohen, who has written a book on medical tourism, says vaccines were meant to go first to those who are most in need" and not to people who are able to travel, who have visas, who are able-bodied."

To put it another way, he says: it's as if someone loans you their car to take your mother to the hospital, and then you decide to take that car and instead of giving it back to the person-or taking other people to the hospital-you run it as an Uber."

Outsourcing ethical quandaries

Robert Amler, the dean of New York Medical College's school of health science and practice, says that encouraging travelers to fly to the United States from places with low vaccination rates-and potentially higher levels of infection-may itself be bad for public health.

Any risk of importing' covid infections will depend on the volume of incoming travelers and the percent of travelers arriving who already have covid infection," says Amler, a former chief medical officer at the CDC. We also can't predict with certitude the city's ability to manage their numbers if they become excessive."

To combat this danger, some people who are traveling to get vaccinated are taking their own precautions to avoid becoming unwitting vectors for the virus-or causing other kinds of harm.

Michael" (also a pseudonym) and his wife flew from Quito, Ecuador, to New Orleans for a five-day trip in mid-May, during which he received the J&J shot and she got her first dose of the Pfizer vaccine.

Michael's family in Canada have yet to meet the couple's twin boys, who were born in January 2020. By going to Louisiana for their shots, he estimates that they've sped up their vaccination status-and therefore their family reunion-by six to nine months.

Still, the couple wanted to make sure they were not taking vaccines that could have gone to someone else. Our first thought was to go to a red state, because we knew supply outstripped demand," he explains.

They took extra precautions before and during their trip, too. Having both contracted covid much earlier in the pandemic, they got antibody tests before flying. Then they kept to themselves to limit their exposure.

The question is really about what states are doing with their resources and which countries are continuing to use them [vaccines] for their own advantage. Globally, that's really wrong."

Nicole Hassoun, Binghamton University

By taking the initiative, they may have dampened the potential negative impact from their trip, but this highlights another problem of vaccine tourism as policy-and of much of the world's covid-19 response in general. Difficult ethical decisions that could have-or, some argue, should have-been matters of policy are instead being pushed onto individuals.

The city is the one who sets the queue," says Pamela Hieronymi, a philosopher at the University of California, Los Angeles. So if you have an issue with vaccine tourists in, say, New York, it seems your complaint should be made to the city, not to the person using the line offered to them."

Nicole Hassoun, a philosophy professor at Binghamton University and the head of its Global Health Impact Project, also argues that while vaccine tourists may grapple with their choice, the real ethical issue is not at the individual level. I think the question is really about what states are doing with their resources and which countries are continuing to use them [vaccines] for their own advantage," she says. Globally, that's really wrong."

There may also be second-order effects like exacerbating local inequality, says Yadurshini Raveendran, a graduate of the Duke Global Health Institute, who points out that richer individuals in low-income countries-those who travel internationally and are thus more likely to take advantage of vaccine tourism-already have better access to health care than poorer people in those countries. Israel has the highest vaccination rates in the world, she notes, but Palestine has administered one dose to just 5% of the population.

Michael, who runs a marketing business in Quito, wants his employees to have the same options he did. I've been thinking about giving my employees a mid-year bonus to fly to the States to get vaccinated if they want," he says. For those who do not already have US travel documents, however, waiting for a visa appointment may take longer than waiting for a vaccine.

Really, it should come back to public health, says Amler, of New York Medical College. Traveling for the vaccine may well be effective for the individuals who get jabbed," he says. However, the much more efficient approach is to ship vaccine to other countries, where their people can be vaccinated in greater numbers and without the inconvenience, expense, and inequitable impact of personal international travel."

Vaccine buffet"

On Saturday, Alex made his way to the Javits Center, the gleaming glass conference center on Manhattan's west side that has been converted first into a covid field hospital and then into a mass vaccination site.

There, presented with the choice of Johnson & Johnson and Pfizer vaccines, he stuck to his plan of the single J&J shot-though he briefly considered whether to supplement either of the shots at Javits with a Pfizer dose later, in the UK. Vaccine buffet," he joked.

It was the most impressive health-care experience I have known," he told me before catching his flight out. It was efficient-he was vaccinated in less than five minutes-and seemed genuinely committed to serving people equitably.

When you see something that fancy... run extremely well, courteously, not with any of the bleakness or contempt sometimes at play with... free public services," he said, it is amazing to see."

His goal accomplished, Alex spent the rest of his weekend biking around the city and enjoying its famous cuisine, eating outdoors. He avoided bars and clubs, despite how much fun it looked," he said. Maybe if I come back once the vaccine has activated."

And despite his expressed dislike of the United States before his vaccine vacation, he's now thinking about coming back. This vaccine thing has shown me that America does have a side to it that cares about basic public health," he said. More than that, once it mobilizes its resources, what it can actually achieve is astounding."

This story is part of the Pandemic Technology Project, supported by The Rockefeller Foundation.