The Unintended Consequences of C0V-19 Vaxxine Policy: Why Mandates, Passports and Restrictions May Cause More Harm Than Good
By Kevin Bardosh, Alex de Figueiredo, Rachel Gur-Arie, Euzebiusz Jamrozik, James Doidge, Trudo Lemmens, Salmaan Keshavjee, Janice E Graham, Stefan Baral
Vaccination policies have shifted dramatically during COVID-19 with the rapid emergence of population-wide vaccine mandates, domestic vaccine passports and differential restrictions based on vaccination status. While these policies have prompted ethical, scientific, practical, legal and political debate, there has been limited evaluation of their potential unintended consequences. Here, we outline a comprehensive set of hypotheses for why these policies may ultimately be counterproductive and harmful. Our framework considers four domains: (1) behavioural psychology, (2) politics and law, (3) socioeconomics, and (4) the integrity of science and public health. While current vaccines appear to have had a significant impact on decreasing COVID-19-related morbidity and mortality burdens, we argue that current mandatory vaccine policies are scientifically questionable and are likely to cause more societal harm than good. Restricting people’s access to work, education, public transport and social life based on COVID-19 vaccination status impinges on human rights, promotes stigma and social polarisation, and adversely affects health and well-being. Current policies may lead to a widening of health and economic inequalities, detrimental long-term impacts on trust in government and scientific institutions, and reduce the uptake of future public health measures, including COVID-19 vaccines as well as routine immunisations. Mandating vaccination is one of the most powerful interventions in public health and should be used sparingly and carefully to uphold ethical norms and trust in institutions. We argue that current COVID-19 vaccine policies should be re-evaluated in light of the negative consequences that we outline. Leveraging empowering strategies based on trust and public consultation, and improving healthcare services and infrastructure, represent a more sustainable approach to optimising COVID-19 vaccination programmes and, more broadly, the health and well-being of the public.
Since 2021, mandatory proof-of-vaccination policies have been implemented and justified by governments and the scientific community to control COVID-19. These policies, initiated across the political spectrum, including in most liberal democracies, have spread globally and have involved: workplace mandates (eg, a ‘no jab, no job’ US federal mandate); green passes/vaccine passports that limit access to social activities and travel (eg, Israel, Australia, Canada, New Zealand and most European countries); school-based mandates (eg, most North American universities); differential lockdowns for the unvaccinated (eg, Austria and Australia); the use of vaccine metrics in lifting lockdowns and other restrictions (eg, Australia, Canada and New Zealand); differential access to medical insurance and healthcare (eg, Singapore); and mandatory population-wide vaccination with taxes, fines, and imprisonment for the unvaccinated (eg, the Philippines, Austria, Greece) (see table 1).
|‘No jab, no job’ mandates
(eg, government employees, key workers, public and private sector)
|Australia, Canada, China, Costa Rica, Croatia, Czech Republic, Denmark, Egypt, Fiji, France, Ghana, Hungary, Italy, Kazakhstan, Latvia, Lebanon, New Zealand, Oman, Poland, Philippines, Russia, Saudi Arabia, Tunisia, Turkey, Ukraine, USA|
|Healthcare worker mandates||Australia, Britain, Canada, Croatia, Czech Republic, England, Finland, France, Germany, Greece, Hungary, Lebanon, New Zealand, Poland, USA (some states)|
|Internal vaccine passports to attend social events, restaurants, bars, nightclubs, fitness facilities, entertainment venues and for bus/train/airport travel||Australia, Austria, Britain, Bulgaria, Canada, Czech Republic, Denmark, Egypt, France, Germany, Italy, Israel, Kenya, Lebanon, Morocco, Netherlands, Romania, Serbia, Singapore, Switzerland, South Korea, Ukraine, USA (some states)|
|School-based mandates||Canada (several provinces), Costa Rica, Lithuania and USA (some states)|
|Full country mandatory vaccination||Austria, Ecuador, Germany, Indonesia, Micronesia, Turkmenistan, Tajikistan|
|Full population mandate for the elderly||Czech Republic, Greece, Malaysia, Russia|
*This is not a comprehensive list of policies, which are rapidly changing in early 2022. This list excludes the use of segregated lockdowns of the unvaccinated (eg, Austria, Germany, Australia), entry requirements for international travel, fines and penalties (including restricted access to social services and medical care, business capacity restrictions and threats of imprisonment) and the use of vaccine metrics to inform other restrictions. There is a significant variation in how countries recognise infection-derived immunity, allow religious, philosophical and/or medical exemptions and incorporate testing as an alternative to vaccination. In addition, some countries have implemented a combination of policies and interventions, so each is not mutually exclusive. As of March 2022, some countries also shifted course and decided to not implement these policies due to changing epidemiological circumstances and sociopolitical resistance. Adapted from Reuters.136
The publicly communicated rationale for implementing such policies has shifted over time. Early messaging around COVID-19 vaccination as a public health response measure focused on protecting the most vulnerable. This quickly shifted to vaccination thresholds to reach herd immunity and ‘end the pandemic’ and ‘get back to normal’ once sufficient vaccine supply was available.1 2 In late summer of 2021, this pivoted again to a universal vaccination recommendation to reduce hospital/intensive care unit (ICU) burden in Europe and North America, to address the ‘pandemic of the unvaccinated’.
COVID-19 vaccines have represented a critical intervention during the pandemic given consistent data of vaccine effectiveness averting COVID-19-related morbidity and mortality.3–6 However, the scientific rationale for blanket mandatory vaccine policies has been increasingly challenged due to waning sterilising immunity and emerging variants of concern.7 A growing body of evidence shows significant waning effectiveness against infection (and transmission) at 12–16 weeks, with both Delta and Omicron variants,8–13 including with third-dose shots.14 15 Since early reports of post-vaccination transmission in mid-2021, it has become clear that vaccinated and unvaccinated individuals, once infected, transmit to others at similar rates.16 Vaccine effectiveness may also be lower in younger age groups.17 While higher rates of hospitalisation and COVID-19-associated morbidity and mortality can indeed be observed among the unvaccinated across all age groups,3–6 broad-stroke passport and mandate policies do not seem to recognise the extreme risk differential across populations (benefits are greatest in older adults), are often justified on the basis of reducing transmission and, in many countries, ignore the protective role of prior infection.
Mandate and passport policies have provoked community and political resistance including energetic mass street protests.20 21 Much of the media and civil debates in liberal democracies have framed this as a consequence of ‘anti-science’ and ‘right-wing’ forces, repeating simplistic narratives about complex public perceptions and responses. While vaccine mandates for other diseases exist in some settings (eg, schools, travel (eg, yellow fever) and, in some instances, for healthcare workers (HCWs)),22 population-wide adult mandates, passports, and segregated restrictions are unprecedented and have never before been implemented on this scale. These vaccine policies have largely been framed as offering ‘benefits’ (freedoms) for those with a full COVID-19 vaccination series,23 24 but a sizeable proportion of people view conditioning access to health, work, travel and social activities on COVID-19 vaccination status as inherently punitive, discriminatory and coercive.20 21 25–28 There are also worrying signs that current vaccine policies, rather than being science-based, are being driven by sociopolitical attitudes that reinforce segregation, stigmatisation and polarisation, further eroding the social contract in many countries. Evaluating the potential societal harms of COVID-19 pandemic restrictions is essential to ensuring that public health and pandemic policy is effective, proportionate, equitable and legally justified.29 30 The complexity of public responses to these new vaccine policies, implemented within the unique sociopolitical context of the pandemic, demands assessment.
In this paper, we reflect on current COVID-19 vaccine policies and outline a comprehensive set of hypotheses for why they may have far-reaching unintended consequences that prove to be both counterproductive and damaging to public health, especially within some sociodemographic groups. Our framework considers four domains: (1) behavioural psychology, (2) politics and law, (3) socioeconomics, and (4) the integrity of science and public health (see figure 1). Our aim is not to provide a comprehensive overview or to fully recapitulate the broad ethical and legal arguments against (or for) COVID-19 vaccine mandates and passports. These have been comprehensively discussed by others. A full review of the contribution of mandates and passports to COVID-19 morbidity and mortality reductions is not yet possible, although some existing studies on vaccine uptake are cited below. Rather, our aim is to add to these existing arguments by outlining an interdisciplinary social science framework for how researchers, policymakers, civil society groups and public health authorities can approach the issue of unintended social harm from these policies, including on public trust, vaccine confidence, political polarisation, human rights, inequities and social well-being. We believe this perspective is urgently needed to inform current and future pandemic policies. Mandatory population-wide vaccine policies have become a normative part of pandemic governance and biosecurity response in many countries. We question whether this has come at the expense of local community and risk group adaptations based on deliberative democratic engagement and non-discriminatory, trust-based public health approaches.