Toward a Healthy Society
 

We’ve Got Better Options

An Open Letter to Premier Ford

Vaccine Passports Are a Failure. Here’s What to Do Instead.

Dear Premier Ford,

We recognize the challenges you face in leading our province during this pandemic, and we respect the authority given to your government to make difficult decisions, including those relating to public health policy.

We write to you, however, out of deep concern about the basis and impact of your government’s proof-of-vaccination requirements, commonly referred to as vaccine passports.

The autonomy of the individual has been highly regarded in Canadian society, culture, and law for as long as this country has existed. It is recognized in the Charter’s protection of individual rights—including conscience, religion, equality, and security of the person—against state intrusion. The autonomy principle has been at the heart of our society’s consideration of significant social issues such as abortion and Medical Assistance in Dying. It is also fundamental to the ethics of public health: patients capable of giving informed consent may decline even life-saving treatment.

Personal autonomy must be balanced with the public good. Your government’s vaccine-passport policy intrudes deeply into personal autonomy, yet fails the balancing test. It is an unjustified, unnecessary, and harmful overreach, with serious short- and long-term consequences. Ontarians need you to replace it with much better alternatives.

Drastic Measures Call for Drastic Times

When you declared in mid-July that you would not tolerate the “split society” that vaccine passports would create, Ontario was coping relatively well with the pandemic. Daily cases and test positivity were low, as were hospitalizations, including ICU occupancy.

What emergency has arisen since that time to necessitate action as drastic as a vaccination-passport plan?

Despite a vague but alarming forecast by the Ontario Covid Science Advisory Table—released the same day as your passport announcement—the “fourth wave” has been underwhelming. Even with the re-opening of schools in September, daily cases have not reached 1,000, while ICU occupancy has not risen even to the Science Table’s best-case projection. In fact, at the time of writing this letter, Covid-related ICU occupancy is actually lower than it was at the time of your “hard no” to passports, at 17 percent of the third-wave peak. Covid-involved patients occupy less than 1 percent of Ontario’s 33,000 hospital beds. The Table’s updated forecast (September 28) describes a much less grim scenario than the previous model—and is already too pessimistic, as ICU occupancy is again below the stated best-case scenario.

Ontario is not in an emergency, and this province’s circumstances do not justify the coercive and disruptive vaccine policies that your government has imposed.

Passport Policy Is Not Evidence-Based

Your government set out three reasons for the vaccine-passport policy: reduce transmission and outbreaks, increase vaccination rates, and prevent further lockdowns. Will it achieve these objectives? Let’s look at the evidence.

Will Vaccine Passports Reduce Transmission and Outbreaks?

The Science Table has stated that there is no evidence of a direct impact of vaccine certificates on viral transmission. Having considered Israel’s vaccine-passport system, the Table added, “It is worth reiterating that there is no direct scientific evidence that the Green Pass was responsible for the sustained decrease in SARS-CoV-2 cases during Israel’s reopening, and there are other international jurisdictions that reopened without vaccine certification, and similarly did not see a rise in cases.”

While numerous studies show that vaccination can reduce the rate of viral transmission, these do not establish that passport policies lead to such a reduction. Passports could even have the opposite effect, due to the behavioural changes they may provoke. For example, vaccinated persons may have a false sense of security in setting that they deem “safe” because they are “passport required,” leading to reduced precautions and greater transmission. Unvaccinated persons, banned from restaurants, fitness centres, and concerts may be more likely to gather together with one another, leading to increased viral spread.

Will Passports Increase Vaccination Rates?

The Science Table has stated that there is no direct evidence that vaccine passports increase vaccination rates. A group of Israeli medical professors has warned that the Green Pass had a paradoxical effect: “The heated debate related to the Green Pass, along with public shaming, has led to resentment and anger. Thus, a substantially greater number of young Israeli citizens, who would have never considered refusing a vaccine recommended by their GP, have refused the Covid-19 shots, and are more attentive to anti-vaccination ideology, which may impede future vaccination adherence.” Another recent study has found that passports may backfire, by increasing vaccine hesitancy.

Your government has pointed to a short-term increase in vaccination bookings as evidence in favour of your policy. After an initial bump in the numbers, however, the data do not show any significant improvement in the trajectory of vaccination. In August, Ontario averaged almost 42,000 daily vaccine doses. Since the passport announcement, it has averaged less than 33,000 daily doses. In fact, some of the most recent weekday dosage numbers have been the lowest for those weekdays since March. The Science Table recently acknowledged that “vaccination coverage is increasing slowly.”

At the federal level, when Canada’s Chief Medical Officer of Health was asked for evidence that vaccine passports will increase vaccination rates, she conceded that she had no good evaluation other than media reports, that the effect “remains to be seen,” and that further study was needed.

Will Passports Prevent Lockdowns?

If evidence is absent that a proof-of-vaccination policy reduces transmission or increases vaccination rates, there is no reason to believe that such a policy can meet the government’s goal of avoiding future lockdowns. In fact, if passports lead to increased transmission, or reinforce vaccine hesitancy, they may make lockdowns more likely, not less.

Passports Disproportionately Affect Marginalized Communities

Proof-of-vaccination requirements impose greater burdens on visible minorities. Data from StatsCan show that vaccine hesitancy is greatest among Black and Métis Canadians and among immigrants. Black Canadians are the most hesitant; there is a 20-point gap between the rate of vaccination in Black Canadians and the Canadian average. Data from the UK show that vaccine hesitancy is greatest in the most deprived areas of England, based on an Index of Multiple Deprivation that measures factors such as income, education, housing, and health. Ontario data too show lower rates of vaccination in economically disadvantaged neighbourhoods.

The scapegoating of minorities has a long history, and the unvaccinated are increasingly being characterized as ignorant and selfish. Yet there is a wealth of information about the complex reasons for vaccine hesitancy among marginalized groups. In a recent brief on vaccine hesitancy, the Science Table observes that “lower vaccine confidence is associated with a complex set of factors including health inequities, systemic barriers to accessing health care, and mistrust in government and health care institutions.”

The practical implications of this burden are appalling. Proof-of-vaccination requirements mean that restaurants, indoor recreation facilities, cultural venues, and many other locations will be available to the vast majority of white or affluent Ontarians, while racialized people, the poor, and recent immigrants will be disproportionately excluded—other than to cook, serve, and clean. In a society that claims to be increasingly aware of social injustice, how can we even contemplate a policy that segregates and marginalizes the already disadvantaged?

These communities, which have suffered a disproportionate number of Covid infections throughout the pandemic, are further harmed by the government’s refusal to recognize naturally acquired immunity—which may be stronger and longer-lasting than that conferred by vaccination.

The lack of firm basis for the government’s policy is having a ripple effect among private-sector employers and universities, among others. This is compounding the disproportionate harm: those already marginalized in our society may now face the additional setbacks of job dismissal and lack of access to education.

And like many of the other pandemic measures, vaccine passports disproportionately harm children, despite their tiny risk of serious illness or death from Covid. Youth whose medical risk-benefit assessment does not favour vaccination, for example, are now banned from restaurants, cinemas, and gyms. The government’s exception for youth sports and recreation is proving increasingly meaningless, as venues and organizations refuse to apply the exception, and local public-health officials impose their own vaccine requirements on youth. And once again, those with the lowest risk from Covid, and with the least control of the situation, are made to pay a high price—one often measured in declining mental, physical, and emotional well-being.

The Policy Is Disproportionate to the Threat

Covid is a deadly threat to certain populations and an extremely small risk to others. While less than 0.071 percent of the Canadian population has succumbed to the disease, our analysis of the data indicates that the rate is a staggering 1.03 percent for those over the age of eighty and a minuscule 0.00015 percent for those under nineteen.

Not surprisingly, the vaccination rates among the most at-risk groups are very high. In Ontario, almost 98 percent of those above the age of eighty, and 96 percent of those over seventy, have had at least one dose; this number falls to 79.1% in the 18–29 age group. Thus vaccination rates are already proportionate to the threat, and a coercive vaccination policy has the greatest effect on those who are statistically at least risk. Those who are at greatest risk gain little in the way of risk reduction, as they are already highly protected by the vaccines themselves.

What is the risk reduction? Provincial data show that approximately two in a million vaccinated Ontarians end up in ICU for Covid-related reasons. Assuming that vaccinated individuals require additional protection, and that vaccine passports provide it, how much is the risk reduced by excluding unvaccinated persons from a restaurant, theatre, or gym? If the result is, say, a 20 percent reduction, to 1.6 in a million—which is unlikely, given the presence of unvaccinated employees as well as the ability of the vaccinated to transmit—is this decrease meaningful enough to justify the damage done by passport requirements?

Individuals and societies have long engaged in risk-balancing and trade-offs. To give just one example, most of us take car trips knowing that this involves the risk of serious accident or death. Public-policy development and analysis also requires a cost-benefit analysis: do the benefits of the policy outweigh its harms?

We have fallen victim to Covid Exceptionalism, where no cost is too great to bear for even the smallest Covid-related benefit. We close schools for months at a time, doing serious mental, emotional, and educational harm to our children, in the hope that we might slow transmission of a virus that poses a minuscule threat to most of them. We restrict sports and recreational activities even as we battle against a disease that disproportionately harms those with underlying health problems. And we impose divisive and damaging vaccine passports in the hope that they might somehow reduce transmission or increase vaccinations—without any analysis of the steep cost.

Ironically, this Covid Exceptionalism may also come at the expense of public health. With so many resources dedicated to fighting Covid, other programs suffer. Hamilton’s public-health unit reports a sharp drop in important childhood vaccinations, such as the one for meningitis. Dental and vision screenings have not happened in schools since March of 2020. There has been a troubling drop in referrals for child-development assessments. Public-health supports for adults who have substance addictions has declined. Death from opioid overdose has increased by 57 percent. Also since March 2020 there have been no routine inspections of food handling, standing water (where mosquitos breed and West Nile virus propagates), or pest control.

Passports Erode Trust

The effectiveness of public-health interventions is always highly dependent on trust in government and in public-health officials. That trust has been battered during the pandemic. We’ve seen complete reversals on pandemic measures such as border closures and masking. We’ve moved from surface transmission to aerosols, from two weeks to “flatten the curve” to many months.

Some of these shifts were unavoidable, as we learned more about a novel virus. However, your government has significantly and unnecessarily eroded trust. You insisted that schools were safe, then suddenly closed them. Communication about restrictions has been confusing and conflicted. The province has gone through steps and stages and zones and colours—and the goalposts have been continually moved, including with respect to vaccination targets. The government has regularly relied on forecasts that proved to be wildly inaccurate. You gave a “hard no” to vaccine passports, then announced them six weeks later and without providing evidence of their efficacy. While you’ve stated that you want the passports to remain in place for the shortest period of time possible, your chief medical officer has made it clear that he is in no hurry to remove them, referring to unreleased modeling showing surges in 2022.

The specifics of the passport program also undermine trust. If vaccines are highly protective, why must we go through such social disruption to keep the unvaccinated away from the vaccinated? If allowing the unvaccinated to dine in a restaurant or attend a concert is risky, how can it be safe to have these same individuals serve customers in these same establishments? If the policy will be in place for the shortest time possible, why is there no exit plan, and why is the government investing in a permanent digital application? If the goal is to prevent transmission, why the focus on vaccination status (which can’t rule out infection) instead of testing? If the goal is to ensure that individuals are protected, why the refusal to recognize natural immunity?

This loss of trust has significant implications not only for the pandemic but for other public-health interventions for years to come.

Passports Create Privacy Problems

Canada’s privacy commissioners have observed that a vaccine passport is “an encroachment on civil liberties that should be taken only after careful consideration.” Due to the impact on privacy, the commissioners argue that passports must pass the text of necessity, effectiveness, and proportionality (that the privacy drawbacks are not disproportionate to the public-health benefits).

Ontario’s Covid-passport program will necessarily need data to operate, and once data exists it can be exposed or misused. This potential intrusion on privacy cannot be justified on the basis of the three criteria stated above.  Further, there are reasons to be concerned about data security, given that Quebec’s passport system was hacked immediately after launch and a private vaccine-passport app exposed the personal information of hundreds of thousands of users.

Premier Ford, it is clear that vaccine passports are an extreme and harmful policy that should be applied only after exhausting other options. Your government can replace passports with evidence-based, less drastic approaches that build trust and do not further divide our society.

Re-Build Trust through Evidence-Based Policy

Reduce Transmission with Rapid Testing

Unlike a vaccine passport, rapid tests can help to establish whether an individual is infection-free and can reduce overall transmission. The province should immediately begin supplying rapid tests at no cost to individuals, families, schools, and organizations. Ontarians could then use these tests when experiencing symptoms, before entering a high-risk location, and in cases of Covid-19 exposure. A “test to stay” program for schools would allow students to remain in class, subject to regular rapid testing, even if a classmate had a confirmed positive case.

Increase Vaccination by Targeting Causes of Hesitancy

Vaccine hesitancy is not a new phenomenon. It has been widely studied, and there are long-standing, known methods for increasing vaccination rate. The 3C model identifies main factors that influence vaccine uptake. The Confidence barrier relates to concerns about vaccine development and safety, the trustworthiness of the system and people delivering the vaccine, and the motivation of the policy-makers. The Complacency barrier reflects an individual’s own assessment of risk and its impact on them and those close to them. The Convenience barrier relates to physical access to the vaccine, affordability, and matters such as language and culture. Yet the Ontario government has failed to implement policy that is based on targeting these three barriers.

Simply communicating information about vaccine safety and efficacy, as the government has done, is ineffective in addressing the complex reasons that underlie hesitancy. Further, addressing hesitancy requires strategies tailored to different populations, based on an accurate understanding of those groups’ reasons for hesitancy. As the Science Table recently concluded, “Community-level strategies, outreach, and interventions can address the drivers of lower vaccine confidence. These strategies include engagement with local leaders, and partnerships with trusted individuals and organizations to build confidence and drive increased vaccine uptake.”

To its credit, the government’s Last Mile strategy adopts some best practices for tackling hesitancy. Unfortunately, one week after the unveiling of that strategy, the vaccine passport was announced, severely damaging the trust required to reduce hesitancy.

Improve Communication with Honesty and Evidence

While vaccines are highly effective in preventing severe illness, messaging has often emphasized their role in preventing transmission. This is a mistake, because each “breakthrough” infection leads some people to conclude that the vaccines are not working as expected—when in fact they are very effective at what they do best. Individuals who were vaccinated to protect others are alarmed to find that while the vaccine confers excellent protection on them, it cannot prevent them from infecting their loved ones. Rather than over-selling the role of vaccines in preventing transmission, the focus should be on their value in preventing illness and death.

Further, fear-based communication should not be employed except in the direst circumstances. The citizens of Ontario have been repeatedly subjected to projections so alarming that even serious situations have come to appear mild by comparison.

Communication should also recognize the stratification of risk. The oft-repeated message that “Covid does not discriminate” is not only factually incorrect but can also lead to an overestimation of risk for some groups, such as children and young people, and an underestimation for others, such as the elderly and those with comorbidities.

The government must communicate policy decisions with scrupulous honesty and full supporting evidence. If the government cannot provide coherent reasons and the best available evidence in support of a policy, it should not implement the policy. Such evidence should explain the cost-benefit analysis, that is, how the good outweighs the harm, including the harm to mental, physical, educational, and economic well-being.

Full disclosure of data should be the default, not the exception. The government consistently reports the vaccination status of those with a new positive test without releasing data on the vaccination status of all those tested—effectively providing the numerator without the denominator. You have also selectively used data—for example, with respect to short-term increases in vaccination appointments—to create impressions that may not be accurate. The out-of-context use of data, and the release of selective data, undermines public confidence and fuels conspiracy theories. In addition, as we noted above, government decisions have downstream effects on civil society as a whole, as non-governmental sectors follow government example in pausing or shrinking programs and services, even where there is no supporting evidence.

Plan and Prepare for Risk

Ontario’s number of hospital beds per capita is among the lowest in OECD countries, while the occupancy rate is the highest. Even before the pandemic struck, this province had very little capacity to deal with any increase in demand. Approaching the pandemic, Ontario had about fourteen ICU beds per 100,000 adults, behind other jurisdictions such as the US (26) and Germany (34). Your own party acknowledged this in campaigning to “end hallway health care.” While this province has juggled resources and cancelled other medical procedures to accommodate Covid surges, this is a short-term solution that creates new long-term problems. Ontario urgently needs a strategy to permanently increase its health-system capacity.

The province must recognize and act upon the stratification of risk. Rather than applying broad measures to the entire population—particularly those such as the vaccine passport that disproportionately affect the lowest-risk segments—Ontario needs a strategy to provide targeted support and protection to the vulnerable. There is now ample data on comorbidities and risk factors, and those with high-risk profiles need to be provided with specific care and support. Policy and communication must recognize the massive difference in risk between various demographics—for example, that an unvaccinated child is at lower risk than a vaccinated adult of any age, and that individuals who are elderly or have certain health conditions are at considerable risk even if vaccinated.

Canada’s pandemic-preparedness plan sets out two goals: minimize serious illness and overall deaths, and minimize societal disruption generally. Premier Ford, the vaccine-passport policy will do little to minimize illness or death and is creating devastating societal disruption. What are the implications for a society where hundreds of thousands are banned from social settings, physical activities, and educational institutions, and have difficulty finding or keeping employment, all based on their medical status?

This is a defining moment for our province, for our government, for our society. The vaccines are incredibly effective at preventing severe disease, and Ontario’s high rate of vaccination is highly encouraging. Will we build trust, approach vaccine hesitancy with compassion, respect our rights and freedoms, and ensure that policy is well grounded in reason and evidence? Premier Ford, we respectfully urge you to take this path and replace the current vaccine-passport policy immediately with much better alternatives.

Prepared by Cardus with the assistance of Ed Bosveld.

Topics: Health