How to get the public to come forward for a jab

The president of the Philippines appeared on television last week to give a late-night address in which he suggested a punitive regime for anti-vaxxers.

“If they don’t want to be vaccinated, they should not be allowed to go out of their homes,” Rodrigo Duterte said. “They may say there is no law, but should I wait for a law knowing that many will die?”

Duterte’s threats represent the most draconian end of the spectrum of government policy aimed at tackling a global issue: how to persuade people to get vaccinated.

Amid a global resurgence of Covid-19 driven by the Delta variant, governments, corporations, leisure operators and universities have begun insisting on vaccination, in moves that run from adding more testing hurdles for workers who refuse, to Duterte’s solution.

The responses to vaccine mandates, passes and passports have varied just as widely. Denmark pioneered vaccine passes with little resistance. In Italy and France, the proposals have prompted thousands to take to the streets against plans that would require vaccination cards for social activities such as dining indoors at restaurants and attending sports events. Germany and the UK have so far resisted a blanket approach, while vaccinations are so popular in Spain that incentives are not deemed necessary.

The force of the escalating momentum behind vaccine mandates, however, has been most visible in the US, where President Joe Biden last week joined big corporations including Google, Facebook and MGM Casinos, as well as the mayors of California and New York, in insisting on proof of vaccination or testing.

“With freedom comes responsibility,” Biden said. “So please exercise responsible judgment. Get vaccinated for yourself, the people you love, for your country.”

The Australian prime minister, Scott Morrison, announced last Friday there would be “special rules” for vaccinated Australians as they posed less of a health risk.

Experts say global efforts to push vaccination have been driven by a number of factors, not least surges of infections driven by the Delta variant but also faltering vaccination campaigns. “It’s the unvaccinated folks that are letting us down,” Kay Ivey, the Republican governor of Alabama, said as her state grappled with the lowest vaccination rate in the US.

There is evidence that insisting on vaccination in certain settings, including healthcare, can significantly increase compliance. In France, almost 5 million people got a first dose and more than 6 million got a second dose in the two weeks after the president, Emmanuel Macron, announced that vaccine passes would be expanded to restaurants and many other public venues. Before that, demand had been waning for weeks. Demand in Italy also increased by as much as 200% in some regions after a “green pass” was announced, according to the government’s special commissioner for vaccinations.

However, the different responses to vaccine resistance – from shaming and coercion, to appeals to altruism and even rewards – have left bioethicists and politicians alike struggling to find a balance.

Most countries have opted, so far, for a carrot-and-stick approach, giving vaccinated people easier access to employment, leisure facilities and travel. Some have encouraged material incentives, such as the $100 payment that Biden has called on US states to offer – an approach also embraced by the Czech government, which has offered two extra days of holiday to state employees who get vaccinated.

Writing this year in the BMJ’s Journal of Medical Ethics, Julian Savulescu, professor of practical ethics at the University of Oxford, points out that the case for mandatory vaccination is usually framed in terms of John Stuart Mill’s argument over the point at which the risk of harm to others justifies restricting an individual’s liberty.

“Covid-19 is almost unique because of the gravity of the problem at the global level,” he wrote. “Not only is there cost in terms of lives from Covid-19, there is also the extraordinary economic, health and wellbeing consequences of various virus-control measures, including lockdown, which will extend into the future.

“There is a strong case for making any vaccination mandatory if four conditions are met: there is a grave threat to public health; the vaccine is safe and effective; mandatory vaccination has a superior cost/ benefit profile compared with other alternatives; [and] the level of coercion is proportionate.”

But he comes down in favour of incentives, concluding: “It is better that people voluntarily choose.”

In France, a health passport has been required since mid-July for venues including cinemas and nightclubs and this will be extended. The policy is backed by about 60% of the population. Only a few months ago barely 40% of French people said they were willing to get the vaccine. This suggests people are open to being nudged. Indeed, a Kaiser Family Foundation poll in the US found 10% of people on the fence, while 6% were waiting for vaccination to be mandatory.

It’s better that people voluntarily choose