Reasons for mandate hesitancy

ANTHONY BUTLER: Compulsion without legitimacy always fails

Persuasion must be the primary driver of compliance in vaccination drive

First published in BusinessLive

28 OCTOBER 2021

At first sight, the case for immediate mandatory vaccination against Covid-19 is strong. Vaccines protect against hospitalisation and death, and reduce the emergence of new variants. The risk of adverse effects is small.

The health-care system is in dire straits, and lockdowns have brought huge economic and social costs. With fewer than 20% of adults fully vaccinated, surely we are justified in using every available lever to increase uptake?

The trouble is that most mandate proponents view them as an alternative to participation in a well-designed and inclusive public health programme, rather than as a supplement to it.

When indoor smoking was banned, no smoking police were needed because the argument about passive smoking had already been won. To see what can go wrong with compulsion, when such legitimacy is absent, look at Gauteng’s road tolling system, with its payment rate of less than 30%.

We have domestic violence laws, but they have not been much enforced because police officers do not believe in them. The vaccine shy can buy a fake Covid-19 vaccine certificate for R5,000 — a potential danger to the credibility of hoped-for international passport schemes.

The classic vaccine mandates were simple and they applied to all the people who would together benefit from them. Children have been vaccinated against tuberculosis for decades. Compulsory vaccination for all front-line health and care workers, sensitively applied, has been introduced in many parts of the world, and there is a case for it in SA today.

An argument could also be made for mandatory vaccination for all over-60s: they are by far the most vulnerable to severe illness and death, half are fully vaccinated, and they will continue to overwhelm the health system at the peak of infection waves.

Even in such cases it is necessary to respect rights and religious beliefs, and to treat persuasion as the primary driver of compliance. A piece of paper is not a substitute for the hard work of providing access to vaccines, combating misinformation, and changing people’s minds.

Most of the vaccine mandates under consideration in SA take a different form. They relate to the employees of private companies, staff and students at educational institutions, and people attending hospitality venues. Excluding unvaccinated people from commercial premises, restaurants, gyms, or shopping malls is certain to prove divisive.

The resources expended on compulsion will be diverted from more productive uses. Mandates’ complex legal process bring high levels of conflict, distracts managers, and reduces trust. The main beneficiaries will be the lawyers.

Indeed, such narrow mandates are likely to be counterproductive because they could well result in a lower level of vaccination than would have been achieved in their absence.

Quite unlike the classic mandates for smallpox or tuberculosis, or a compulsory post-60 Covid-19 vaccine, these are not in any sense “universal”: they are targeted at small groups of people who enjoy formal employment, are mostly well-educated, already enjoy easy vaccine access, study in universities or attend cultural events.

Turning such “insider” institutions into long-term zones of compulsory vaccination will undermine any broader vaccination drive. Consider how elite schools worsen the performance of failing public schools, by recruiting the best teachers and poaching the activist parents who can hold teachers to account.

Citizens with private health-care absorb the services of the majority of doctors, but they also disengage from the problems of the wider public health system. Private security guards make wealthy insiders feel safer, but displace crime to areas that do not enjoy their protection.

Broad mandates can sometimes work, but we need persuasion before, and then alongside, the compliance they help to secure. As vaccine boosters become normal, mandates that reinforce and then cement the insider advantages of small groups could easily undermine the wider national vaccination project.

• Butler teaches public policy at the University of Cape Town.

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