In the Fog of COVID-19

Part 2: A Q&A with applied medical anthropologist Kevin Bardosh, about the potential fallout from vaccine mandate and proof policies

In Part 1 of this series I introduced you to Kevin Bardosh, the corresponding author of a recent preprint study that hypothesizes that punitive measures, such as vaccine mandates, which were implemented in tandem all over the world, could turn out to be counterproductive, causing damage to public health, rather than the other way around.**

The paper was published on the Social Sciences Research Network (SSRN), a repository for uploading preprint articles, which are those that have yet to be peer reviewed.

The paper lists a number of possible long-term impacts from vaccine mandates including how they can actually backfire and lead to a reduction in the uptake of future public health measures, including routine vaccinations. Also, mandates and proof policies that restrict access to employment, education, and civic life impinge on human rights and “promote stigma and social polarization,” which in turn adversely affects health and wellbeing. The paper cautions that measures like mandates should be “used sparingly and carefully to uphold ethical norms and trust in scientific institutions.”

Ultimately the paper calls for an evaluation of these consequences.

Kevin Bardosh is an applied medical anthropologist at the School of Public Health at the University of Washington. Photo from Twitter

The first thing I noticed about the study is that the nine authors come from a wide range of academic backgrounds, including law, bioethics, public health, infectious disease, global health, pediatrics, and epidemiology. The list includes Janice Graham who teaches in the Division of Infectious Diseases and the Department of Pediatrics at Dalhousie University.

Bardosh studied at the University of British Columbia (UBC) and then did his PhD at the University of Edinburgh and is currently with the School of Public Health at the University of Washington. He’s an applied medical anthropologist and has focused on using social science and community engagement to improve public health delivery and policy.

I reached out to Bardosh for an interview. Here is our wide-ranging discussion.

[The following interview has been edited for length and clarity]

Linda Pannozzo (LP): What is an applied medical anthropologist?

Kevin Bardosh (KB): I work at the intersection between social and political science, and public health and medicine. What I've done in over 20 countries is understand what are called local realities: people's perceptions, their practices, their behaviours, the way they think about the world and interact with risk factors, that put them at risk of infectious diseases, zoonotic diseases, animal diseases and human diseases. So often the focus is on making an intervention more effective, and increasing compliance, like increasing vaccine uptake or acceptance of health care services. The way that I like to think about that is that you have community factors—people's perceptions of health and perceptions of health care services. But you also have the way public health interacts with the public. I try to always bring that self-critical lens to the public health community. If you want to improve your programs, you need to pursue policies or interventions that enhance human agency and empower people rather than just telling them what to do.

LP: In your paper you say, “while COVID-19 vaccines have had a profound impact on decreasing global morbidity and mortality burdens, we argue that current population-wide mandatory vaccine policies are scientifically questionable, ethically problematic, and misguided.” If vaccines have a profound impact on these health outcomes, why doesn’t that justify the imposition of vaccine mandates?

KB: That's a good question. There are a lot of other public health interventions that if we mandate them for people, it would significantly decrease global mortality and morbidity rates. We generally don't like to use the sort of nuclear bomb of mandates, and we have mandates for childhood vaccinations and those are always in general implemented in ways that are in dialogue with the public and also in times of political calm. We've never had this type of medical mandate, certainly in our lifetime. It's unprecedented. The types of policies also—the passports, the restrictions based on vaccination status—are also unprecedented, and they were implemented in the context of a year plus of uncertainty and anxiety created by lockdowns, which were also an unprecedented set of public health measures that were implemented across the world. The other issue here is, are these measures proportionate? The notion of proportionality in bioethics is that a medical intervention should be implemented in a way that considers reducing possible harms and tries other less coercive and forceful options before resorting to a more forceful approach.

LP: I know someone reading this might say, well these restrictions were unprecedented but so was the pandemic. Does an unprecedented event call for unprecedented measures?

KB: We're having a larger debate about that still today. Were the lockdowns actually proportionate and effective? Were there other options that we could have pursued rather than pursuing months and months of lockdowns? So, there's a large debate here—from an epidemiological standpoint—about the effectiveness of lockdowns, mask mandates and vaccine mandates. I think it's going to take us a little while to digest that information and scientifically to come to a consensus about this and I still think it's a little bit early to do that. I am also a little bit concerned that we have fallen into ideological camps and that it's difficult for people to have a nuanced conversation about these issues scientifically.

We’ve all lived through two years of this and many of us have different forms of trauma, depending on how your life was affected or how people around you were affected. We’re not really understanding how to deal with that as a society. So, I'm quite concerned about the future, our memory of the pandemic and how we are going to digest what's just taken place.

LP: Your report looked at what you called the “global turn” towards mandatory COVID-19 proof-of-vaccination policies and how the rationale for vaccination shifted over time. It started out that vaccines were to protect the vulnerable, and this rationale shifted to the need to reach vaccination thresholds to “end the pandemic” and “get back to normal.” Once thresholds were reached the rationale then shifted to universal vaccination to “reduce hospital and ICU burden” because of the “pandemic of the unvaccinated.” Then everyone had to be vaccinated including very young children. Even those who had been previously infected with COVID were told to get two shots. Then came the boosters. What do you think this shift in rationale did to public confidence?

KB: I think the shift has had a profound effect for a certain segment of the population and it's hard to know exactly how large that segment is. It obviously differs from country to country in the way that the public health authorities and governments communicated that shift. But what we see is a couple of major things that played into the loss of trust in the United States, and I would say this is also the same for Canada. The denial of so-called natural immunity or acquired immunity by public health authorities was probably one of the most damaging communication mishaps of the vaccination rollout.

The idea that if you’ve had COVID-19, you're not protected and you need to get vaccinated, otherwise you're not going to be considered epidemiologically immune. It doesn't make scientific sense and so that produced a huge amount of material for what we call cognitive dissonance.

Also, our policies in North America were quite stringent—you can't get on an airplane unless you show your vaccination certificate, you can't get into restaurants, you can't keep your job—but did not incorporate natural immunity or prior infection. This created an immense amount of anger, and justifiably so, because you have people who've recovered from a disease and scientifically, they have immunity equivalent to vaccination. That's what the studies show pretty much universally. That's now generally accepted. But now we're going to fire them because they don't want to be fully vaccinated.

A lot of policies are still maintaining this stance. If you look at university policies in the United States, I think there's about 400 universities that are mandating boosters for their students and if you don't have your third shot, you are going to be dis-enrolled from university or have to follow testing requirements. These universities generally don't equate prior infection with vaccination.

LP: You’re talking about blanket vaccine policies. Why do you think public health policies didn’t reflect the emerging science?

KB: That's complicated, because again, we're always trying to summarize these very different countries, different provinces or states that pursued different policies. But I think in general, we have an unprecedented lockdown, for months. People are very scared. They're very concerned and then we put our eggs in the vaccination basket saying, “Look, we have these vaccines that are coming online. They're going to save us and return life to normal.” There was a lot of hope that the vaccines would stop transmission. There were scientists from the beginning who were saying, “Actually, we don't know, it might not.” But in general, public health authorities sold that to the public, saying, “You need to go get vaccinated. We're going to return to normal. It's going to stop transmission.” And then that was shown not to be the case.

LP: So, doesn’t it make more sense in that situation for public health policy to reflect this uncertainty as opposed to doubling down or sticking to out-of-date messaging?

KB: Yes, there's a lot of literature about the way that policy-making occurs in times of crises, where you have a narrowing of vision, where solutions are defined in a certain way, and then authorities feel like they need to keep moving with the same package of solutions, despite the fact that reality is showing otherwise. And I think we've seen that a lot with the pandemic. It's very difficult to pivot and admit also that you had some aspects wrong.

LP: That makes me think about the issue of trust. If you had a populace that was very trusting of the government or of public health, that pivoting wouldn't be such an issue. But maybe there wasn't enough trust. Do you think that played a role in why public health in many places just stuck to their messaging despite new information emerging?

KB: Yes, absolutely it did. Some countries like the UK, for example, never mandated vaccination and they had very high vaccination rates. They never mandated vaccination for their students in universities, and they also have pretty high vaccination rates. Scandinavian countries, for the most part, also didn't mandate. So absolutely, it's a crisis of trust, and that trust goes both ways: the public trusting scientists, scientific institutions, government regulatory bodies, but then also those expert bodies also trusting the public.

And this gets to the question of, what is the role of the government? What's the social contract? If you look at the United States, there was a recent Pew survey where 24% of people said that they trust the central government. It's very low but if you go back to the 1950s, that rate was closer to 75%.

So, the COVID vaccination program is occurring in this history of trust with government institutions. Also, Pfizer has had one of the largest criminal fines in the history of the corporate world, but now everyone's being told to trust Pfizer. There's also a lot of corruption in medical research itself. Marcia Angell, who was the editor-in-chief of the New England Journal of Medicine, has written extensively about this.

I'm very concerned going forward, that lockdowns, mask mandates, but especially the vaccine mandates have generated a huge amount of social polarization that's going to be hard to undo. I'm also worried that public health might continue to go down this new culture of mandating things rather than listening, rather than trying to enhance human agency and to encourage people to make their own health decisions and also to put into place the structural, foundations to help facilitate that, whether it's paid sick leave, air purifying systems, etc.

LP: In your paper you noted that there was often incomplete, contradictory, and misleading information being communicated by health authorities. You talked earlier about how natural immunity wasn’t recognized, but can you provide another example?

KB: At the beginning of the vaccine campaign, Biden and lots of other world leaders said publicly the vaccine is not going to be mandatory, then they changed course. They also said that the vaccine would stop all transmission. I spent almost a year of the pandemic in Europe, and I've been following the situation in Europe and Israel for a long time and I remember watching in the summer of 2021—Fauci, the CDC, the White House—making statements that if you get vaccinated, you are not going to get COVID-19. It was clear at that point from the data in the UK and Israel that it was not the case; that you could get COVID-19 if you were vaccinated. Yes, your chances of hospitalization and death were much reduced, but you could still get the virus. So, it was very clear that those were not scientifically accurate statements, but it was being used to increase vaccination rates and I think this notion of selectively informing people to shape their behaviours is part of this noble lie that has eroded trust in scientific institutions. It's basically, “We know better and we're going to selectively tell you the information that you need to hear in order to adopt something because if we make it too complicated, you might not listen to us or you might not go out and do what we think is going to be beneficial for the public's health.” I think that backfires, and I think it's backfired here.

LP: Your paper notes that during the pandemic, a number of very legitimate concerns were raised including concerns about vaccine safety, lack of long-term safety data, and, as discussed, a disregard for natural immunity. There was also a public perception that some of this information was being actively censored or selectively presented in the media. Do you have any thoughts on why the media was engaged in this?  

KB: It's a good question. I think the White House had given a billion dollars to the mainstream media in the US to help promote the COVID 19 vaccines. So, there's obviously a large incentive to present the information in a specific way. Having worked and continuing to work in public health, I understand this. It's really hard to try to communicate complex topics to people. But this is actually part of a much larger conversation that's taking place right now in our societies about the censorship of online information. In a way, it's almost like information mandates: Who can spread information? What information cannot be spread? At the end of the day, we are centralizing a lot of power in technology companies because they're the ones who are mediating or deciding what is misinformation and what isn’t—these fact checkers—and I think the competence of these people to really engage in these fluid and changing scientific questions, especially when there's a lot of uncertainty, is questionable.

So certainly, at the beginning, when the myocarditis safety signals were coming out, there was a big effort to downplay that, especially for young boys, which it seems that's where the largest risk for a second dose of vaccine is right now.

LP: A subject I’ve been interested in is how restrictions, like lockdowns, were justified to protect the health care system— but how little was done over the last two years to shore up these systems. Your study argues that the “scapegoating” of the “the unvaccinated” as the cause of health system collapse diverted public attention away from the deep structural challenges facing public health capacity in many countries, and also away from global equity failures, essentially “absolving” governments of their role. Your paper also says the challenges facing health care capacity are rooted in decades of neoliberalism and austerity measures. Can you expand on this subject?

KB: How much have we heard in the media or in the government about systemic problems in our health care system and how the pandemic has exacerbated that? I think the focus has been on trying to ensure the success of behavioural interventions, having people wear masks, get vaccinated, social distancing, stay at home, those are behavioural interventions. They put the individual in focus rather than the systems that exist around those people and I think the focus on individual behavioural change has detracted from those larger structural issues.

LP: Since governments have mandated vaccines, making them a requirement to access work, travel, or participate in civic life, shouldn’t the government also bear a higher burden of responsibility to ensure transparency about vaccine efficacy, risk, and safety?

KB: Yes, absolutely. There are two things I would say about this. The first is we have a crisis in accountability and transparency in medical science—in the pharmaceutical industry—and this is well known and well documented. An NGO group—through the Freedom of Information Act—requested the original clinical trial data from the FDA and Pfizer. They wanted to have all of the documents that the FDA used to review and make their regulatory decisions about the Pfizer-BioNTech COVID 19 vaccine and the FDA and Pfizer came back and asked for 75 years to release those documents. That does not provide much confidence in transparency. Even if there are no red flags with the vaccine—this procedure sends a signal saying we have something to hide. Peter Doshi at the British Medical Journal has written about this. Independent scientists who are not tied to Pfizer or to pharmaceutical companies or the government need to review this data and that's why it would seem like, especially in this circumstance where we mandated the vaccine in so many different ways, this would have been part of the social contract. We're going to mandate a vaccine, but all of the information is accessible. We're not going to hide anything. I think that it's a symptom of the lack of transparency that we have.

The second issue here is that all vaccines do have adverse effects. This is well recognized and there are people who have vaccine injuries from the COVID -19 vaccines. They might be rare, but they have occurred, and as far as I can tell, those individuals have not been treated with very much dignity, and the vaccine court system is also a broken system and needs to have a little bit more public scrutiny about it for those individuals.

Protesters gathered at the Peace and Friendship Park, Halifax, January 23, 2022. Photo: Linda Pannozzo.

LP: The following is a quote from your study [I’ve added in the hyperlinks]:

Some of the major concerns raised by the public include adoption of implantable tracking devices (including micro-chips), digital IDs, the rise of social credit systems, and the establishment of authoritarian bio-surveillance governments. Paradoxically, the COVID-19 pandemic happens to coincide with far-reaching technological advances that do provide the capability for new and future forms of mass state surveillance. For example, biocompatible intradermal devices have recently been created that can be used to hold vaccine records, while multifunction implantable microchips (that can regulate building access and financial payments, much like cell-phones) are now available on the market. Aspects of vaccine passport policies combined with these innovations – as well as censorship by social media companies of vaccine trial issues from reputable sources like the BMJ – may reinforce and exacerbate suspicion and distrust.

When people have raised concerns about capabilities like these in the context of the pandemic they tend to be labelled “conspiracy theorists.” Do you think it’s possible the pandemic has been used to usher in or accelerate some agendas that pre-dated it?

KB: That's a great question. Naomi Klein is a famous Canadian social theorist and she's written extensively about disaster capitalism—that during a tumultuous socioeconomic event, powerful people take advantage of it. The rich get richer, the poor get poorer, and the pandemic has done that. Wealth has gravitated upwards and it’s been further removed from working class individuals and from small and medium sized businesses, who had to shut during the pandemic. Also, in the Global South, countries have had a hard time recovering from the economic shock of lockdowns and the pandemic in general. One hundred million people have been pushed into severe poverty because of the pandemic.

I would call some of these so-called conspiracy theories alternative explanations for what's occurring or alternative power theories. Certainly, some of them are proper conspiracy theories, but not all of them are. I think we really struggle with a lexicon of how to describe these anxieties about the future. Obviously at the centre of this discussion is the World Economic Forum and something called the Fourth Industrial Revolution, which is, and I'm using a quote from the [WEF] itself, the “merging of biological, digital and physical reality.” There is an emerging anxiety about artificial intelligence, about robotics, about automation.[1] There's also a profound social degradation that's been taking place for a while with television culture, social media culture in young people and also in adults, resulting in an increase in loneliness and social separation.

So, the pandemic has occurred within this historical moment where there's an immense amount of anxiety about climate change, about geopolitics, about economic change, technology and I think these conspiracy theories reflect that anxiety and they should be understood within that context.

LP: Can you talk a bit about what you refer to in the study as the “scapegoating” of the unvaccinated?

KB: It’s just classic discrimination, creating an ‘other.’ It’s obviously polarizing, and it creates an environment where people feel at liberty to discriminate against other people based on their medical decisions. There are studies to show that individuals who've remained unvaccinated for COVID-19 are more likely to have a past history of abuse, of mental illness, of being mistreated by medical authorities, of having adverse effects from other types of drugs. They also might have different political viewpoints about the role of the government.

There's so many different ways that people approach this issue, and this is why the reactance theory is so important here. This is the notion that if you're going to take away my freedom, I'm going to find a way to get it back in some way to reassert myself, my dignity, my personhood, whether it's through protest, which we've obviously seen, or possibly in other unhealthy ways. One of the major arguments of the paper is that mandates have a backlash.

Austria is an example of a country that imposed the first population-wide mandatory COVID-19 vaccination policy in late 2021. All adults needed to be vaccinated and they had police officers walking around asking people about their vaccination status. They had a lockdown that was only for the unvaccinated, and then they were going to impose fines on unvaccinated people. Just a couple of days before the fines were going to come into effect, they rescinded the policy.

If you look at the vaccination rate in Austria, 20% of adults are unvaccinated for COVID-19 and if you track that with the mandates, you don't see a very large increase, so my sense is that the Austrian mandatory vaccination policy was a failure. But now you're going to have to deal with the social repercussions of having 20% of your adult population who now have a grievance against the state and against public health and are energized in protest movements and feel like their freedom has been taken away from them.

LP: And what do you make of the belief or assertion made by public health officials that unvaccinated people put other people at risk?

KB: I think at this point the evidence is quite clear that the reduction in transmission between an unvaccinated and vaccinated person, certainly for OMICRON but also for DELTA, is relatively negligible. There's a range of studies, a range of data, but in general, these are not durable vaccines. They don't stop transmission. They also wane so that the effect on transmission also wanes quite quickly after a few months. So, the justification that we need to mandate COVID-19 vaccines because they are going to stop transmission and they are going to keep other people safe, doesn't appear to be strongly supported by the scientific evidence.

LP: Despite the fact that many countries are aware that the vaccine mandates and passports are having deleterious effects on societal cohesion, among other things—while also not slowing the spread of the virus—many are keeping these policies in place. Why would countries keep these policies in place once they realize they don’t make scientific sense and could be causing more harm than good?

KB: On the one hand, there was a majority of people who supported these policies in a lot of places: over 50% of the electorate supported vaccine mandates. So, if you're a politician, you're looking at those polls and we do unfortunately govern now by opinion poll, which is a very questionable way of actually running liberal democracies, in my opinion.

We’ve also had two years of stress and fear, and stress does not help us make rational, cool-headed decisions. I hope that we can all stand back now and really take stock of what's taking place and the appropriateness of these policies.

LP: Given we’ve had mandates imposed once, and we don’t know what to expect with the virus in the future, how can we ensure they aren’t just automatically brought in again?

KB: We don't know what's going to happen with the virus. We have this hope that we are at the end of the pandemic, but there might be a new variant that emerges that defies our vaccines, and also natural immunity has been shown with coronaviruses to wane after one to two years. There's a lot of uncertainty involved and I want to recognize that. I'm not minimizing COVID-19 at all. Also, I think that we have now set up a system where the public, but also public health is primed to jump into a mandate mentality. So, again, I think there needs to be some cool-headed, serious, scientific discussion and evaluation of the effectiveness of these measures that we've taken over the last year and consider their harms, the unintended consequences, as well as look at how effective they were at stopping viral transmission, hospitalizations and deaths from COVID-19. We need a proper cost benefit discussion, which I haven't seen much of over the pandemic and I think many people agree with me.

One of the major motivations for the paper was to say, we've been talking about the benefits of vaccination, we've mandated vaccination, but have we considered the possible harms for certain types of people? And really, the paper does say that these are hypotheses and we are sort of calling for the public health community to look at some of these issues and to study them in more detail.

[Bardosh anticipates the paper will appear in a peer-reviewed journal in the next month or so]

Addendum: I think it's important to add more detail on some of the concerns held by folks who are not vaccinated. This is from the paper itself: "Unvaccinated or partially vaccinated individuals often have concerns that are based in some form of evidence (e.g. prior COVID-19 infection, data on age-based risk, historic/current trust issues with public health and governments, including structural racism), personal experiences (e.g. direct or indirect experience of adverse drug reactions or iatrogenic injuries, unrelated trauma, issues with access to care to address adverse events, etc.) and concerns about the democratic process (e.g., belief that governments have abused their power by invoking a constant state of emergency, ignoring processes of public consultation, and over-relying on pharmaceutical company-produced data in their decision-making) that may prevent or delay them from choosing to vaccinate."

** Postscript: This preprint article has since been peer-reviewed and published by the British Medical Journal.

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[1] The fourth industrial revolution “is characterized by a fusion of technologies, such as artificial intelligence, gene editing, and advanced robotics in a way that is ‘blurring the lines between the physical, digital and biological worlds.’ It will disrupt nearly every industry in every country, creating new opportunities and challenges for people, places and businesses to which we must respond.” From https://www.gov.uk/government/publications/regulation-for-the-fourth-industrial-revolution/regulation-for-the-fourth-industrial-revolution. The phrase, “blurring the lines between the physical, digital and biological worlds,” can be found in a number of places, but both the phrase, and the term, “Fourth Industrial Revolution,” was coined by Klaus Schwab, who heads up the World Economic Forum.