VACCINE hesitancy, vaccine reluctance, and vaccine resistance with restricted vaccine access in the general population all threaten our pandemic suppression programme.

Vaccine refusal issues are less easily addressed and often sidestepped. Continuing to advise, inform, support, and persuade those not vaccinated is widely and rightly accepted as the way forward – but is there a time limit on how long such an approach should be tried as Covid cases rise yet again?

Is mandatory vaccination the way forward for some frontline workers? This does not entail compulsory vaccination because those who decline vaccines would be free to leave and seek other work. Ethical, legal, and pragmatic arguments exist for and against mandating vaccines, but too often the popular debate is framed only in terms of libertarian versus authoritarian ideas. The public health dimension vanishes and periodically unintended consequences flowing from vaccination policies, good and bad, can be missed.

The position of non-vaccinated health and social care workers differs from the wider population in several respects. Front line workers have extensive contact with the public, their own family and friends, co-workers in vital public services, and patients and others in both health and social care settings.

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There is much we do not know. At what point does non-vaccination threaten, damage, or protect public health? Can and should those who, after almost a year of Covid vaccination availability in Scotland, decide not to be vaccinated over-ride the public health arguments for vaccination?

The Royal College of General Practitioners believes the benefits of persuasion for health care workers over the long term outweighed mandating staff but does not conclusively evidence its case. The Royal College of Nursing argues mandating staff creates division where there should be “conversation”. Yet divisions emerge from non-mandating and the related risks of patients, colleagues, and non-vaccinated workers falling ill are marginalised or ignored.

The BMA suggests mandatory vaccinations would lead to an exodus of health and social care staff in areas of greatest deprivation and so further damage the health and care of the most vulnerable populations. Yet it does not flag unvaccinated risks to patients in the same way. There is also some evidence from employers who required staff to be vaccinated that take-up rates rose considerably in sectors where jobs were relatively well-paid and fulfilling.

Better pay and conditions for low-paid health and social care workers should therefore be “part” of the vaccination picture.

Last week, the UK Government made Covid vaccination a “condition of deployment” for all public-facing staff in England’s health services from April 2022. The Scottish Government has no plans to do likewise for NHS workers. This is apparently partly because Scotland’s vaccine take up rates among these workers have been described as “incredibly high”.

The Scottish position may yet be challenged and there are major contradictions in their vaccine position. For example, you should be vaccinated to enter a nightclub or major music and sports event, but not if you work in a hospital and care home.

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As of November 12, 94.1% of Scottish frontline health care workers in specified roles – some 98,796 – had been double-jabbed, which means around 6300 workers may not have been. We do not know what the percentage is of “any frontline health and social care workers” who have been double-jabbed. Nor do we know what, if any, effect the presence of these unvaccinated workers has had on Covid figures.

Delays in getting boosters muddies the waters further with regard to risks from and exposure to non-vaccinated or one-vaccinated workers. If, however, public health is precautionary, it would seem unethical to wait to see what effect unvaccinated workers have on Covid morbidity and mortality because any adverse effects will not be reversible.

MANDATING arguments involve both public health and equity. In a pandemic, especially where there are vulnerable populations, there are concerns about waning vaccine effectiveness and worries about the development of variants.

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Double jab rates in deprived parts of Scotland, although still high, are also around 15% lower than other parts of the country. In these areas, the populations will be even more vulnerable to Covid, and to contact with non-vaccinated or non-double-jabbed health and social care staff too.

The First Minister has reportedly stated she does not favour compulsory vaccination because of ethical considerations and apparently does not mention ethical arguments for compulsory vaccination.

This looks like cherry picking. Privileging the rights of vaccine “refusers” over the rights of patients and care home residents (be they vulnerable or not) , co-workers and the public to be better protected from risks merits serious discussion.

As the journalist Francis Ryan (below) recently observed, “a healthcare worker’s right to be unvaccinated does not trump a clinically vulnerable person’s right to life”.

The National: journalist Francis Ryan.

We could paradoxically find that in England employees take action against employers and the UK Government for mandating, whereas in Scotland, there could be legal cases against employers and Government for non-mandating if linked to Covid illnesses and death among other employees, patients, or the public.

On this basis, vulnerable and other groups in England will be better protected from Covid than those in Scotland. Again, Ryan noted: “Two-thirds of all coronavirus-related deaths in the UK have been disabled people and hospital-acquired Covid has led to the deaths of at least 8700 inpatients in England since the pandemic began.

It is perhaps reflective of the low value we put on disabled and older people’s lives that it is even a debate that society should take every measure possible to protect them.”

The ethical and public health case for mandatory vaccinations of health and social care workers in this context looks unanswerable.

Vaccination, whether mandated or not, remains only one part of the pandemic solution. Mitigation measures such as improved ventilation, physical distancing, passports, testing and tracing, self-isolating, PPE and masks remain critical strands in prevention strategies within and beyond health and social care settings.

Professor Andrew Watterson is an expert in public health and environmental justice at the University of Stirling