Enforcing COVID-19 vaccines is the only way to Combat Hesitancy

Updated: Jul 17

Opinion by Chanel Best. This piece is part of The Global Vaccine Challenge, a series by Chanel Best on the inequalities in access and distribution of COVID-19 vaccines.

A gloved hand holding a small vial that reads "Viral Vector Vaccine, COVID-19."

In 2019, the World Health Organization (WHO) named vaccine hesitancy one of the 10 biggest threats to global health [1]. In the wake of COVID-19, this threat has become greater in the wake of COVID-19 as pandemic conditions provide further fuel to anti-vaccination movements. Statistics Canada found that around one in four Canadians experience some degree of vaccine hesitancy, including those in healthcare [2]. Scientists fear that vaccine hesitancy could drive the growth of COVID-19 variants that threaten the efficacy of current vaccines. If this threat materializes, then greater political action may become necessary to counter skepticism. Making vaccines mandatory is controversial, but, in the past, it has proven effective in ensuring herd immunity. Today, introducing restrictive policies may be the only option to combat vaccine hesitancy, as current approaches to curb hesitancy are not enough to compete against misinformation and political distrust.

How has Vaccine Hesitancy been Addressed in the Past?

Figure 1: An English engraving “The Cow-Pock-or-the Wonderful Effects of the New Innoculation showed those who had been vaccinated growing cow heads from fresh injection site. The 200-Year History of the Anti-Vaxxer Movement: From 'Cowpox Face' to Autism Claims, Newsweek. March 13, 2019. https://www.newsweek.com/history-anti-vaxxers-vaccination-1358403

The distrust of inoculations is as old as vaccines themselves. The anti-vaccine (or anti-vax) movement, long driven by substantial misinformation, is over 200 years old. The first modern vaccine for smallpox was created in 1796 by Scottish doctor Edward Jenner, and by 1800, the emergence of anti-vaccine rhetoric and propaganda was already underway [3]. In an 1806 essay, for instance, British doctor, Benjamin Mosley, described fictional post-vaccination symptoms like "cowpox face" and speculated that women "might wander in the fields to receive the embraces of the bull [4]."

In 1853, the first mandatory vaccination policy was introduced in England and Wales for infants under 3 months old. The Vaccination Act was met with dissent from some who felt the policy was coercive. The policy was controversial because it included fines or jail time for parents who refused to vaccinate their children [5]. Despite the quick formation of anti-vaccination leagues, the policy appeared successful, with two thirds of children having been vaccinated and death rates dropping by the 1960s [6].

In the United States, by the early 20th century, around half of states had compulsory vaccination laws; however, in 1903, Minnesota introduced a law banning mandatory vaccinations after officials gave in to pressure from anti-vaccine groups, a measure that would later be blamed for a smallpox epidemic in 1924 that saw 28,000 people infected [7]. Around the same time, the U.S. Supreme Court ruled against Henning Jacobson, a man arrested for defying mandatory vaccination laws in Massachusetts. In this landmark 1905 case, the Court upheld states’ authority to impose mandatory vaccination in order to protect the public health and safety of the community through herd immunity [8].

So, there are some notable precedents to inspire today's policies for dealing with vaccine hesitancy. As the controversy around smallpox vaccines illustrate, mandatory vaccine policy will always be met with public dissent, but they do work.

Comparing Approaches

In the past, public awareness campaigns, material incentives, and restrictions have been used to increase the percentage of vaccinated persons in a population and challenge hesitancy.

Awareness campaigns are a traditional approach to promoting vaccines through increasing public interest. Public messaging for vaccines can come in the form of education campaigns or social media posts publicizing politicians and celebrities getting their shot. Further approaches to encouraging vaccine uptake, namely incentives-based and restrictive approaches, have sought to move beyond just communicating vaccines’ health benefits to the public.

Incentives are used with the hope of motivating vaccine hesitant people by attaching additional benefits to receiving the vaccine. On the state and provincial levels, monetary lotteries that only those with a dose of the vaccine can participate in have emerged as a form of incentive. The first vaccine lottery was created in May in Ohio. The campaign saw a short-term boost in vaccinations after offering cash prizes. During the pandemic, Manitoba and Alberta have also developed their own vaccine lottery that offers adults monetary prizes of up to $100,000 and those aged 12 to 17, scholarships [9]. However, data analyzed in a Politico article, entitled “Million-Dollar Lotteries Fail To Cut Through Vaccine Apathy,” shows no proof that vaccine incentives are working. As Irwin Redlener, director of the Pandemic Resource and Response Initiative at Columbia University noted, the strategy is “just not working, people aren’t buying it. The incentives don’t seem to be working — whether it’s a doughnut, a car or a million dollars [10].” If people do not value material incentives enough to receive a vaccine, then it makes the goal of achieving herd immunity increasingly difficult without other measures.

In past vaccination efforts, restrictive approaches, which prevent non-vaccinated persons from participating in specific activities, have proven effective at increasing vaccination rates. In 2014, the Ontario government began a crackdown on unvaccinated students and instructed schools to issue suspension warnings for students who did not provide proof of up-to-date vaccinations, as per the 1990 Immunization in Public Schools Act [11]. A report by Wellington-Dufferin-Guelph Public Health presents evidence that enforcing immunization through suspension remains an effective means of improving vaccination rates [12].

Applying the restrictions approach in the current COVID-19 landscape is possible. Earlier this year, British Colombia amended their Motor Vehicle Act to allow the Insurance Council of British Colombia (ICBC) to prevent anyone with an outstanding fine related to COVID-19 from renewing their driver’s licence [13]. Vaccination mandates rarely force individuals to be vaccinated or use criminal penalties for noncompliance. Such restrictive vaccination policies enforce vaccination as a condition for, say, attending school or working in industries like healthcare. For example, Western University has decided students will have to be vaccinated to live on campus [14]. Policymakers can use the incorporation of restricting civil liberties to enforce COVID-19 vaccines.

Why is this Controversial?

Despite past examples and evidence that enforcing vaccinations helps achieve herd immunity, mandatory vaccines are unlikely to be ethically justified. It is unclear that a mandate is necessary to achieve the objective of herd immunity, and with limited supply remaining a barrier in some regions, enforcing vaccines may not be universally feasible. Additionally, the suggestion of mandatory vaccine policies is also met with low public approval. Only 39% of Canadians favour a mandatory vaccine policy [15]. Low favourability among the public means we must also be mindful of what effects mandatory vaccines could have on public trust towards the government. 

Three common trends appear when analyzing arguments against mandatory vaccines.

Ethical arguments around bodily autonomy are justified by existing ethical frameworks in feminist theory. Arguments made by minority groups against mandatory vaccines are trauma-centered responses and therefore valid. Freedom and rights based anti-vaccination arguments are just as common. But these arguments do not have the same legitimacy because exercising ones right to freedom by refusing the vaccine infringes on the rights of others by lengthening a public health crisis.

Understanding the origins of vaccine hesitancy and being critical of the effectiveness of current efforts to persuade people to take the vaccine, while also considering the role misinformation plays, leaves few viable options for confronting hesitancy. But if herd immunity is lagging, restrictive vaccination policies may be the only way to get there.

Note: On July, 12 2021, Prime Minister of France Emmanuel Marcon, announced a wide set of restrictions for the unvaccinated. Beginning in August anyone over the age of 12 entering a restaurant, café, cinema, theatre, museum, theme park, cultural centre or shopping centre, hospital, and passengers on long-distance trains in France will have to show a special Covid health pass that has proof of dual vaccination or a recent negative test for COVID-19. The measures also include mandatory vaccinations for workers in healthcare. Vaccine checks on those workers will begin in September, with a risk of sanctions or fines for non-compliance. After these announcements more than 20,000 people a minute booked appointments to receive vaccines[16].

  1. World Health Organization (WHO). Ten Threats to Global Health in 2019, 2019. https://www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019.

  2. Statistics Canada. COVID-19 vaccine willingness among Canadian population groups, March 26, 2021. https://www150.statcan.gc.ca/n1/pub/45-28-0001/2021001/article/00011-eng.htm.

  3. Walting, E. The 200-Year History of the Anti-Vaxxer Movement: From 'Cowpox Face' to Autism Claims, Newsweek. March 13, 2019. https://www.newsweek.com/history-anti-vaxxers-vaccination-1358403

  4. hi Wing Lau, T. The Routledge Companion to Health Humanities, Historicizing anti-vaccination, Inventing Edward Jenner. February 2020. ISBN 9780429469060.

  5. Chi Wing Lau, T. February 2020.

  6. Walting, E. March 13, 2019.

  7. Walting, E. March 13, 2019.

  8. Walting, E. March 13, 2019.

  9. MacLean, C. Manitoba to give nearly $2M in prizes to people who get vaccinated, CBC News. June 9, 2021. https://www.cbc.ca/news/canada/manitoba/manitoba-covid-19-vaccine-incentives-1.6058815.

  10. Goldberg, D. & Doherty, T. Million-dollar lotteries fail to cut through vaccine apathy https://www.politico.com/news/2021/06/19/million-dollar-lotteries-vaccines-494989.

  11. Immunization of School Pupils Act, R.S.O. 1990, c. I.1. https://www.ontario.ca/laws/statute/90i01.

  12. Wellington Dufferin Public Health. Immunization for Children in Schools and Licensed Child Care Settings Report, Board of Health, BH.01.SEP0518.R21. September 5, 2018. https://www.wdgpublichealth.ca/sept-2018-boh-immunization-children-schools-and-licensed-child-care-settings-report.

  13. Brown, S. COVID-19: Have unpaid COVID fines? ICBC may not renew your driver's licence or insurance, Vancouver Sun. May 12, 2021. https://vancouversun.com/news/local-news/covid-19-have-unpaid-covid-fines-icbc-may-not-renew-your-drivers-licence-or-insurance.

  14. CBC News, Western University tells students they must be vaccinated to stay in residence, May 27, 2021. https://www.cbc.ca/news/canada/london/western-students-vaccination-requirements-1.6042422.

  15. Global News, 39% of Canadians say coronavirus vaccine should be mandatory: poll, October 14, 2020. https://globalnews.ca/news/7395956/canadians-coronavirus-vaccine-mandatory-poll/.

  16. Henley, J. France reports rush for vaccines after Macron tightens Covid rules, The Guardian, Tuesday July 13, 2021. https://www.theguardian.com/world/2021/jul/13/france-reports-rush-for-vaccines-after-macron-tightens-covid-rules.