At the end of 2020 and in the early months of 2021, I wrote an interdisciplinary review of lockdown policies, which looked at the evidence and arguments from biomedical, socio-economic, psychological and ethical perspectives. I was at the time surprised by the amount of research about lockdowns that was monolithically focused on COVID-19 outcomes while ignoring of all the potential collateral damage, and was sure that a more holistic take was necessary. My article was put through peer-review, accepted in July 2021 and finally published in late 2021. You can read it here.
Now that vaccine passports and mandates have become the latest frontier in the Covid debate, blinkered monolithic thinking is being shown in political and media discourse, just as happened with lockdowns earlier in the pandemic. Accordingly, here I present an interdisciplinary critique of these measures, taking into account biomedical, social, psychological and ethical perspectives. In relation to my attitudes to vaccines per se – I am vaccinated against COVID-19, and my daughter has had all her standard childhood vaccinations to date. I am fully supportive of vaccines as an elective and informed choice.
The biomedical perspective – transmission and serious illness
The main argument for vaccine passports is that COVID-19 vaccines reduce transmission, therefore being in an environment in which only vaccinated individuals are allowed means your chance of getting COVID-19 from others in the room is lessened. It is unclear if the vaccines ever lessened transmission, even before Omicron. Studies on Delta showed marginal and temporary benefit in transmission, while others showed none. Now with Omicron, it is becoming increasingly clear that vaccines do not reduce transmission. This negates the principal argument for vaccine passports.
The rationale for population-wide vaccine mandates (being pursued in Austria, Ecuador, Tajikistan and Indonesia), is that obligatory vaccination is required to avoid the health system being overwhelmed by unvaccinated individuals. At this point in the pandemic, that proposition does not withstand scrutiny. The burden of the unvaccinated on the health system is not what it appears from media headlines. For example, in the U.K. at the peak of the Omicron wave, 14% of hospital beds (19,000 of 140,000) in the U.K. were taken up by COVID-19 patients (and the U.K. has fewer hospital beds per capita than most other developed countries). The proportion of those being admitted as hospital inpatients over the age of 18 that were unvaccinated was 29% according to the U.K. Vaccine Surveillance Report from the period of peak cases (January 13th). So at the peak of the Omicron wave, 4% of total hospital beds were being occupied by the unvaccinated.
This does not add up to a scapegoat-able claim that the unvaccinated are in danger of overwhelming the health services. This picture will differ by country, but broadly the same pattern is manifest across all countries that are considering mandates – the burden of COVID-19 care for the unvaccinated is a small fraction of urgent and non-urgent care.
Meanwhile, from an overall health perspective, in the U.K., overall deaths for the winter of 2021-22 are at approximately average for this time of year and well below the 2017-18 flu season. The graph on page 2 of this U.K. Government excess mortality document shows this clearly.
As a final biomedical point, it matters deeply what kind of precedent is being set here for the future of public health. What is permitted now by way of Government control of individual lives will set a benchmark for arguably more extreme surveillance or segregation measures in the future. How far would politicians and public health officials want to take this argument that public health outcomes justify social exclusion or violation of bodily autonomy? If the minimal threat posed to the health service by the COVID-19 unvaccinated justifies these measures now, how about a system to exclude or penalise smokers? Obese people? Heavy drinkers?
Ethical arguments – informed consent and risk-reward ratios
Informed consent and bodily autonomy are integral to medical ethics. To override them for the public good requires a cast-iron argument and evidence that is almost irrefutable. Mandated measures for public health and safety that override consent do exist in liberal democracies. An example is wearing seatbelts in the front seat of a car. This is ethically justifiable as wearing a seatbelt does not infringe any basic liberties such as bodily autonomy or freedom of movement, and it can’t kill you. In contrast, vaccines do have the potential for harm.
In the U.K., the Government’s Yellow Card system counts approximately 1,900 deaths due to adverse reaction to the vaccine. In the U.S., the Vaccine Adverse Event Reporting System (VAERS) has counted approximately 19,000 deaths following a vaccine adverse reaction. Some argue these figures are an overestimation given that the deaths are not medically proven to be caused by the vaccine, while others argue that they are likely to be an underestimation given that only a fraction of adverse reactions get reported to these systems. But if we take the Yellow Card figure for the U.K., on the basis of 48,000,000 people double vaccinated, this means approximately a one in 24,000 chance of dying from a Covid vaccine. Crucially, the age of those who have died from vaccine side-effects in the U.K. has not been released. A concern is that vaccine fatalities may include a high proportion of young people, given that vaccine adverse events are more common in the young.
Evidence of the potential adverse side-effects of the vaccine is still being found. For example, a concern has been recently highlighted about unexplained excess deaths in young men since the vaccine rollout. In January 2022, a spinal condition was added to the list of AstraZeneca side effects. In relation to this, it is worth bearing in mind that it took three years after delivery of the vaccine for swine flu in 2009 before it was finally accepted that it caused narcolepsy in some people, leading to a flurry of lawsuits. Where things end up for the COVID-19 vaccines is still a wait-and-see situation. Full approval is not yet granted to them in the U.K., and many countries have limited their use in the young (for example, Belgium does not allow Moderna to the under-30s, Japan recommends against AstraZeneca for the under-40s, and Taiwan has halted use of Pfizer in the under-17s). All considered, we don’t know what the long-term burden to the health system will be from those who have been vaccinated.
When a medical procedure comes with risk of harm, as is the case with the COVID-19 vaccine, it must be left to the informed consent of the individual. Japan is an exceptional model in this regard. Japan’s Ministry of Health of health website encourages citizens to receive the vaccine, but stresses it is not mandatory. Those taking it in Japan are required to be informed of the factual risk of side-effects such as myocarditis before they give their informed consent to be injected.
A final ethical point about vaccine mandates and passports is that enforcement of this biometric surveillance and control requires heavy-handed policing to monitor, penalise, collect fines from and arrest people who dissent. The internet is full of videos of people being arrested in places such as Australia or Canada for simple activities like going to a café without a smartphone or vaccine passport. This kind of law enforcement behaviour undermines a healthy and productive relationship between police and citizens. The definition of a police state is one where a government exercises an extreme level of control over civil society by means of the police, and vaccine mandates or passports require that a society moves very clearly in the direction of a police state to be enforced.
Psychological arguments – persuasion and coercion
Those who are unvaccinated include the informed and the uninformed. This is reflected in findings on a recent study from the U.S., showing a high proportion of high-school educated but also PhD-level educated in those expressing vaccine hesitancy. Coercion via mandate and passport is a poor way of aiming to positively persuade uninformed individuals to get vaccinated. For this group, mandates and passports may temporarily lead to increased uptake, but it will do so at the risk of further anti-establishment resentment, and an even greater scepticism of authority. This may in turn lead to generalised vaccine scepticism over time in countries that are applying vaccine mandates and passports. For those who have not taken the vaccine due to a more informed position, mandates and passports tend to lead to a principled refusal, and we are seeing this in the National Health Service in England, where 70,000 or more staff may choose to lose their job rather than take the vaccine by mandate. It is increasingly clear that persuasion through coercion fails in a liberal democracy. Clear information and informed consent remain the best foundations for health behaviours in good times and in bad.
Social arguments – discrimination
Vaccine passports are intentional sources of discrimination, as they exclude a portion of the population for participating in communal activities. This group, as described above, includes the highly educated and the relatively uneducated. Even if the data pointed towards tangible medical benefit and no dangerous side-effects, which they manifestly do not, the heritage of this kind of group discrimination and the scapegoating that comes with this process, is sufficient argument against the policies, as eloquently argued by Reicher in the BMJ. The heritage of excluding groups from communal buildings has a terrible legacy – it builds mistrust, fear of the other, aggression, and scapegoating. A scapegoated group to blame for the continued problems of the pandemic may be politically judicious in the short-term for leaders looking to deflect blame from themselves. However, it is unjustifiable from a medical, psychological or ethical perspective. Indeed, fomenting a them-and-us attitude via vaccination status is likely to lead to social division and unrest. That prediction seems to be coming true in Canada currently – the Freedom Convoy protests in Ottawa has brought the city to a halt and is likely to run for weeks. It has raised an astonishing $9 million dollars in a few weeks via GoFundMe, showing massive popular support for the movement. A similar situation is likely to follow in France, Italy, Austria and other states that have chosen this path. A European Freedom Convoy is organised to converge on Brussels on February 14th.
Those who support vaccine passport systems such as those now being used in France and Italy will argue that excluding the unvaccinated is fundamentally different to exclusion based on race or ethnicity, given that the unvaccinated have made a choice. However, the difference between vaccine segregation and ethnicity-based segregation is not so great. There is an overlap, which relates to the aforementioned group who decline vaccination based on no information or misinformation. Disadvantaged ethnic groups in countries tend to be over-represented in the unvaccinated, and this likely relates to their lack of access to information, language barriers or cultural barriers. Those barriers need to be overcome for a healthy, integrated society, but vaccine passports and mandates will entrench them and create even fewer opportunities for minority social participation.
Vaccine passports also discriminate against people who don’t possess a smartphone. In the UK, just 65% of adults over the age of 65 have a smartphone. Most countries or states with vaccine passports will offer a printable alternative, but for the elderly who don’t have a smartphone, are they likely to be able to find their way to a website and print out a vaccination passport form? No. Vaccine passports will thus force many of the elderly into a kind of continued lockdown and retreat from public life. This is unacceptable.
Summary
In summary, arguments at all four levels analysed here point in the same direction: vaccine passports and mandates must be dropped immediately by any country or state that has adopted them. Vaccines have protected the elderly and vulnerable from COVID-19 since being rolled out, but that does not by any means equate to becoming a requirement for participation in society and the economy. Liberal democracies must trust the foundational principles of informed consent, bodily autonomy and equality of opportunity. We must respect those who draw different conclusions from what remains an inconclusive situation in relation to vaccine side-effects and benefits. The story is still unfolding.
Acknowledgements
Thanks to Louisa Tomlinson, Pascal Michael, David Bell, Abir Ballan and Todd Kenyon for their comments on a draft of this manuscript.
Dr. Oliver Robinson is Associate Professor of Psychology in the School of Human Sciences at the University of Greenwich.
