Introduction
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).
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.18 19
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.31–33 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.