What to do about the anti-vaxxers? There are three options

The experience of France and other European countries is that, faced with serious barriers, large numbers of unvaccinated people drop their objections very quickly

Backstage of the Christmas pantomime at No 10 (or rather, last year’s performance during “lockdown”) there is a serious public policy debate about measures to curb the spread of the omicron variant of Covid.

There are still many uncertainties about omicron, but early indications are that it is more easily transmitted than earlier variants but no more of a threat to those who are fully vaccinated and have a booster jab. The government is moving belatedly to step up the pace of vaccination of all adults to ensure they have a third dose. They are right to do so.

A more controversial issue is over restrictions on social interaction. Over the last two years policy argument has raged about the balance to be struck between curbing personal freedoms in order to stop the transmission of the virus, hospitalisation and deaths, and the economic and wider costs of those curbs.

The parameters of that debate are however quite different to a year ago. The success of the vaccination roll-out in Britain and most other developed economies has changed the balance of the argument in two key respects. First, the level of vaccination, with boosters, combined with the antibodies of the many millions who have had Covid, protects a large majority from the risk of further serious infection. Consequently, Covid has become a disease we can live with.

Secondly, the threat to society at large from omicron comes not from the virus itself but from pressures on the NHS from rapidly growing numbers of serious infections among the unvaccinated. The pressures are felt by NHS staff but also those whose treatment for other diseases is disrupted or postponed. There is therefore a big divide opening between the vaccinated, who want to get on with their lives, and the unvaccinated who are at growing risk and are responsible for restrictions affecting everyone.

The harm caused to society by the unvaccinated is partly that there is increased transmissibility. The evidence is contested but there are clear findings from the research conducted at Imperial College by Professor Lalvani’s team and the UK Health Security Agency, published in The Lancet, that while vaccinated people can pass on the disease, they do so at lower rates (about half). Then, additionally, because they are unprotected, unvaccinated people are themselves at greater risk of becoming very unwell and placing serious pressures on the NHS.

A head of steam is therefore building up behind the idea that further curbs on freedoms should mainly apply to the unvaccinated. A recent article by Andrew Neil in the Mail spelt out very forcefully the logic which leads inexorably to some form of discrimination through vaccine passports.

The idea that unvaccinated people should be treated differently and discriminated against as a conscious policy runs into several objections. The first is widely heard but weak: that people have a basic right to exercise a choice not to be jabbed. But if that exercise of choice harms others, it is not a valid choice. We do not allow motorists to choose to drive the wrong way down a motorway or allow people to choose to hold noisy, all-night, parties whenever they wish. 

A more serious point is that there are some people who have genuine health reasons for not being vaccinated, because of allergies or compromised immune systems. But ways can be found to accommodate them, such as GP certification to explain any exemption.

The most difficult objection is that there are distinct groups who have refused injection not as a result of laziness or bloody-mindedness but because of widespread suspicion, based on experience, that the authorities are not to be trusted. In the US, some black Americans cite the history of being used for scientific experiments. Others have been fed plausible misinformation by community leaders. But these arguments are wearing a little thin. Elected ethnic minority figures, such as the Mayor of London, have given strong, clear leadership on the need for vaccination. And indulgence of anti-vax sentiment may do more to inflame ethnic divisions than to insist on conformity.

This is a classic case of the distinction between “freedoms from” and “freedoms to”.  It is objectionable that the freedom of a majority from restrictions on their daily lives might be removed by the freedom of a minority to refuse vaccination.

Furthermore, the experience of France and other European countries is that, faced with serious barriers, large numbers of unvaccinated people drop their objections to vaccination very quickly. France was regarded as implacably anti-vax; but quite suddenly that has changed.

As we consider what to do about the unvaccinated here, there are three options – compulsion through employment conditions; changes to rights of treatment under the NHS; and a more comprehensive vaccine passport system. 

It is, of course, impractical and unacceptable to have refuseniks dragged away, held down and forcefully injected. However, compulsion as a condition of employment is already happening for NHS and care staff in the UK and elsewhere. There is a risk of losing some quality staff who, for whatever reason, refuse to comply. But that risk must be set against the wider public interest including maintaining the confidence of patients and those who use care services.

Another approach is to penalise the unvaccinated by restricting their access to the NHS. As things stand, large numbers of unvaccinated people who present themselves at A&E with severe Covid symptoms will get preferential treatment over those with lethal but slowly evolving diseases like cancer. Most of us, and I suspect most medical professionals, would regard that as fundamentally unjust.

However, doctors have a professional duty to treat the patients in front of them. People who put themselves at risk by base jumping, climbing vertical rock faces without support or getting seriously drunk can expect the same treatment as everyone else. A pandemic is however quite different from individual eccentricities or indulgence. The sheer numbers of infected cases prevents other patients receiving the care they need.

Nonetheless, providing less comprehensive treatment to the non-vaccinated, sending them home with drugs and breathing aids, would amount to a death sentence in some cases and no doctor wants to be required to make such decisions, especially as the facts may not be clear in an emergency.

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A less drastic option would be the Singapore model: charging for the cost of treatment for the unvaccinated. But the objection in principle is that it would be seen as creating a precedent for wider patient charging. Such is our attachment to a “free” NHS (for those judged eligible, which excludes foreigners) that I suspect there would be little political support.

That leaves vaccine passports: the need to show proof of vaccination (or a negative test) before events with much social mixing. The UK is introducing a fairly minimal version of this approach affecting nightclubs and big gatherings. Austria has had an extreme version which effectively confines the unvaccinated to their homes except for essential shopping. Other countries are somewhere in between.  If the omicron wave gets out of control the UK will move inexorably in Austrian direction.

By tempering the vaccine passport with the option to show a negative test instead – but extending the requirement to a far greater range of social settings – we would protect the socially responsible majority and the economy, and maintain the dubious freedom to refuse vaccination for those who really insist on it. I suspect their numbers would dwindle quickly, as in France, and we would achieve greater protection from the disease and greater freedom for everyone in 2022.