Why Are America’s COVID-19 Vaccine Cards So Big?

This spring, as New York City warmed up and the local vaccination rate surged, I met my best friend for our first restaurant meal together in months. As soon as we sat down, she began rifling through her purse. “I have something for you,” she told me. From her bag came a rectangle of clear, thick, double-layered plastic—the kind of display pocket that often dangles at the end of a lanyard. My friend had swiped a handful from her office’s supply closet. “It’s for your vaccine card,” she explained. But I already knew.

When I got my first shot, in late February, I sat in the mandatory waiting area, holding my new card in one hand and my wallet in the other, trying to understand why the two objects weren’t compatible. I contemplated where I should put this brand-new golden ticket, ultimately sliding the thin piece of too-large card stock into an envelope I found in my tote. I’m going to either lose this or destroy it, I thought to myself.

Indeed, I lost it—at least for a little while. Despite dutifully sliding the card into its new protective pocket after lunch with my friend, I eventually found myself tearing my apartment apart searching for it, for exactly the reasons I had feared: It was the wrong size for the one place where most people keep all their important everyday documents, and of too nebulous a purpose to sit safely in a drawer with my birth certificate and passport. Could it unlock some sort of privileges at the airport? Were restaurants going to check it? Did I need to take it to medical appointments? My card had gotten shuffled into a sandwich baggie filled with extra masks, not to be rediscovered for six weeks.

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With all due respect to our country’s overworked and undersupported public-health apparatus: This is dumb. The card is dumb, and it’s difficult to imagine a series of intentional decisions that could have reasonably led to it as the consensus best pick. Its strangeness had been a bit less important in the past seven months, when evidence of immunity was rarely necessary to do things within America. Now, as Delta-variant cases surge and more municipalities and private businesses begin to require proof of vaccination to patronize places such as restaurants and gyms, the rubber has met the road on this flimsy de facto verification apparatus. It’s not the highest-stakes question of this stage of the pandemic, but it’s one that’s become quite common: How did we end up with these cards?

The logical step here is to ask the CDC what the deal is, but the agency, which issues the cards, isn’t saying much about them. It did not respond to my request for comment, and little is known about how the cards came to be. Their mysterious origin is tied up in the country’s light approach to keeping tabs on vaccinations, which, as my colleague Ian Bogost wrote in May, amounts to something of an honor system. America has no national database that records shots, and the Department of Health and Human Services does not know who has or hasn’t been vaccinated; the federal government relies on reporting from the states, and state governments have highly variable attitudes and strategies about vaccination and reporting.

The persistent informality of these efforts is especially odd because Americans always were going to need a way to demonstrate their COVID-19 vaccination status to others. Nearly as soon as the pandemic began, experts and government leaders around the world began discussing how people might be asked to prove immunity in order to return to some elements of everyday life. The Atlantic ran its first story on the topic in April 2020. While other countries have implemented national verification systems during their vaccine rollouts, the United States’ verification efforts have varied wildly. Some states, such as California and New York, are now trying to retrofit digital vaccine verification into the country’s piecemeal system, whereas others, such as Texas and Florida, have passed laws to punish businesses that try to check patrons’ status or have outlawed the use of verification systems entirely.

So now the only consistent vaccine documentation in America is the too-big, too-little cards, and they are precisely the “bad outcome” that the Princeton professor Ed Felten predicted in December they would be: a document designed to be a personal record that ends up being used as an official license to breathe on strangers in sealed rooms.

Read: A better solution than laminating your vaccine card

Although the CDC isn’t talking, there is much to suggest that the vaccine cards were indeed never meant to be evidentiary. The card’s template was initially publicly accessible on a number of state-government websites, and is still available on Florida’s. An official in Missouri, where the template was taken down at law enforcement’s request, told NBC News that the state had originally posted it to make things easier for local vaccine providers. Try to imagine governments freely distributing their templates for driver’s licenses, passports, or other documents intended to certify a particular identity or status. The vaccination card is much closer, physically and aesthetically, to an appointment-reminder card you get from the dentist when you schedule your next teeth cleaning. (The FBI has since clarified that printing your own vaccine card is illegal.)

When you hold one of the vax cards, you can see how people would immediately misunderstand it as something that’s meant to be kept on your person. Although too big for a wallet, they’re also too small to easily keep track of outside a wallet. “It’s absolutely the wrong size,” Alison Buttenheim, a professor at the University of Pennsylvania School of Nursing who has studied vaccine documentation, told me. She noted that the cards don’t match the dimensions of any other common vaccine documentation she knows of, including the yellow booklet that the WHO uses for international travelers, which is bigger. As we were talking, Buttenheim briefly misplaced her own folded-over vaccination card; it slid a little too far into one of her wallet’s compartments. (At this point, I should admit that I again lost mine in my apartment for most of a day after getting it out to examine for this article.)

A better option, Buttenheim told me, might have involved two pieces: a larger document with information about follow-up appointments and side effects, for example, which would have cut down on the amount of stuff that needed to go on a more durable, wallet-size, and ideally harder-to-fake plastic card. Such a system would also avoid data-privacy concerns that can come with smartphone-app verification systems, as well as the accessibility issues inherent in requiring people to own a smartphone to prove their ability to work or access services. Those requirements are the hardest on the poor or elderly, for whom COVID-19 poses the greatest health risk. And the technology for some of those apps is, uh, still being refined. New York City’s smartphone verification app—not to be confused with New York State’s Excelsior Pass, or its new Excelsior Plus Pass—appears to accept photos of restaurant menus as proof of vaccination. A spokesperson for Mayor Bill de Blasio has said that’s because the city’s app doesn’t verify anything; it simply gives users a place to store a photo of their vaccine card.

But let’s hold our focus on the most important point of inquiry: What’s the deal with the cards? When Bogost looked into them in May, a historian at the CDC guessed that their design was likely inherited, but no one seemed to know from what. “Like so much of our vaccine rollout, I’m guessing someone had to produce this in, like, eight hours,” Buttenheim said. “There was not time to workshop it and focus-group it and pressure-test it and rapid-cycle prototype it.” But she also noted that the card’s backside includes a date in tiny print in the lower left-hand corner, which likely indicates when the design was finalized or printed. Buttenheim’s and mine are both dated September 3, 2020—months before any vaccine received an emergency-use authorization from the FDA, and before the mass-vaccination effort had taken any real shape. Preparation well in advance is important, of course, but it’s even better if it retains some flexibility to respond to new needs (such as vaccine verification) as they arise.

Read: The futility of vaccine passports

What seems most likely is that maybe no one thought far enough forward to consider the cards’ eventual off-label usage. “While I don’t know for sure, the size of the COVID-19 vaccine card is likely a prime example of public health being a bit antiquated,” Jen Kates, the senior vice president and director of global health and HIV policy at the Kaiser Family Foundation, told me via email. “The large vaccine cards on paper are a relic from the past, and they’ve never been updated. No one thought to do so now.” She compared the low-tech cards to some jurisdictions’ use of fax machines to send data to the CDC at the height of the pandemic.

Everyone I talked with eventually landed on the same conclusion, more or less. “I don’t think it’s that deep,” Chelsea Cirruzzo, a public-health reporter at U.S. News & World Report, whose tweet about the oversize vaccine cards recently went mega-viral, told me. “I think someone just printed out a bunch of cards that are easy to write your name and vaccine brand on, without thinking about wallets.” Maybe the dimensions were determined by the even subdivision of an existing inventory of card stock. I even called my mom, Pamela Mull, who has considerable professional expertise when it comes to federal agencies printing out flimsy and questionably useful cards—she worked for the Social Security Administration for decades before retiring in the mid-2000s. Her verdict? “Nobody thought about it.”

For weeks, I’ve been trying to figure out why I feel so antagonized by something as innocuous as the moderately suboptimal design of the vaccine cards. Sure, they’re unwieldy on a number of levels, and they’re being asked to serve a purpose for which the country should have—and certainly could have—provided a better, more secure answer. But so what, really? It’s just a typical story of American government inertia. Maybe hoping for more is naive.

That assumption is precisely the problem. When I was vaccinated, in late winter, my appointment was at one of the country’s first FEMA-run mass-vaccination sites, on its second day of operation. Even as the site was still getting its sea legs and the military personnel who ran it were learning their new duties, it was a marvel of efficiency at a grand scale; I went from freezing at the back of a block-long line to sitting in the mandated post-vaccination waiting area in less than 15 minutes. On my second visit, I didn’t wait a single second. At its peak, the site vaccinated 3,000 Brooklyn residents every day in the gymnasium of Medgar Evers College, all with an astonishingly effective government-funded vaccine that had been developed years faster than any other immunization in human history.

The American vaccination mobilization, at its best, is a clear testament to how untrue the country’s common assumption of government ineptness can be. When funding and resources and political will are concentrated, doing something that will make millions of people’s lives better—even something that sounds like a pipe dream—is possible, and it becomes possible extremely quickly. The inconvenient paper vestige that vaccinated Americans now carry of that experience is an exasperating reminder not of the shots themselves, but of all the other missed opportunities our government has had to ease the pandemic’s many predictable problems.