Toronto Star Article

Are passports mandates the best way out of the pandemic? NO We need certificates, but not coercion

Debates about vaccine mandates tend to conflate technology with policy, but these urgently need to be considered separately. There is no question we need some form of robust, tamper-proof vaccine certificate; without such a document or technology, very few vaccination policy options can even be considered, let alone implemented. Moreover, certificates should be issued federally, given their importance for safe interprovincial and international travel. But none of this requires forcible vaccination or firing anybody.

Every child should be taught only by vaccinated teachers, and every hospital patient and long-term-care (LTC) resident should have only vaccinated caregivers. But this, too, does not require forcible vaccination or firing anybody.

An effective alternative to forcing vaccination is described by "nudging theory," as explained in Richard Thaler and Cass Sunstein's 2009 book "Nudge." It is a manual for inducing desired behaviours without force, and therefore without reactionary rebellion. People's behaviours can be profoundly shaped by using levers of effort and convenience, without recourse to submission or punishment. Perhaps presciently, much of this American book is devoted to explaining why this strategy is particularly effective in the face of Republican notions of self-reliance and freedom.

I had the opportunity to observe nudging in action several years ago at a U.S. cancer hospital full of immune-compromised patients, but where staff uptake of flu shots had been less than 10 per cent. The hospital had considered forcible vaccination, and the resulting maelstrom was predictably violent: the flu shot was declared dangerous, ineffective, unconstitutional. Unions were up in arms over their members' ultimate loss of agency: body self-determination.

The hospital then abandoned force and tried nudging instead: every staffer would either have a "vaccinated" sticker on their ID badge, or be masked at all times, from November to April. (An admittedly quaint inconvenience by today's standards, but staff had a legitimate choice of principle vs. comfort.)

What happened? Compliance rose to over 95 per cent and the vitriol dissipated. But that is only half the story. I persuaded hospital leaders to let me survey 1,500 staff about their motivation to get vaccinated, with a very high response rate. The results were staggering. About three per cent of respondents expressed angry defiance. Everybody else declared they got vaccinated out of a desire to protect their patients, themselves and their families, along with the principle that vaccination is part of professionalism in health care. The unwavering anti-vaxxers were a minuscule minority.

How did this flip happen? Well, convenience is a significant driver of behaviour, and as social psychologists have known for 65 years, people will readily change their attitudes to match their voluntary actions, even when this behaviour is externally induced.

How can we use this knowledge to protect schoolchildren, LTC residents and hospital patients? Every employee could be given the choice of vaccination or reassignment to a drab cubicle farm, populated by masked, unvaxxed colleagues doing less stimulating administrative work than they were trained to do. This would keep them away from the vulnerable - and the job that most would likely prefer.

Our growing embrace of mandatory vaccination and the rise of mobs protesting at hospitals and throwing stones at politicians is not a coincidence. We place ourselves in great social peril when we underestimate how many will turn to violence when they perceive a loss of agency coupled with a perception of injustice.

Wars on terror produce more terrorists, and forcible vaccination produces more hardened anti-vaxxers. Vaccination policies, deftly based in nudging, could solve three problems at once: our children and elders would be safe, our vaccination rates would be high, and the anti-vax mob would dwindle. "Nudge" was aimed at influencing libertarian Americans, but Canada has a far-right wing, too: "Nudge" should be required reading for anybody working on public COVID-19 vaccination policy.

There is one more institutional nudge desperately needed, but rarely discussed. All admissions applications to schools for health-care workers, teachers and first responders should include an oath to vaccinate. This would not deprive anybody of agency, but would nudge would-be applicants to orient themselves appropriately for their chosen career.

Colin Furness is an epidemiologist and assistant professor at the University of Toronto's faculty of information.