Throughout the pandemic, physician-epidemiologist Stefan Baral has provided clinical care and public-health support to people experiencing homelessness in Toronto. He has also been an outspoken critic of certain public-health measures, including requiring people to provide proof of vaccination to enter various venues. We interviewed him about his stance on this issue, and what follows is a transcript of this interview, edited for length and clarity.
Why do you oppose using vaccine certificates?
With a fantastic team of nurses, I’ve led the vaccination of thousands of people in the shelter system. Most of the folks I work with have grave challenges. Based on what I’ve seen, I’m concerned that we are excluding folks who are vaccinated but cannot provide evidence of that vaccination or do not have identification, which is a perennial challenge. For example, there are folks who don’t have a health card, who have developmental delays, older folks. We needed more time to think about how vaccine certificates were going to be rolled out; we’ve never had a vaccine mandate for activities of daily living and we have not given thought to how that affects pretty significant portions of our population. Ultimately, communities already on the margins are now the ones that risk being further excluded from indoor spaces, which is particularly concerning as winter arrives.
There are three principles that are integral to public health. One is equity: we do more for people who need more. The other two are social justice, which means we balance the benefit and the burden of any intervention at a population level, and participation, which means we engage the populace in having input into any intervention. From an equity perspective, we needed systems in place to help get vaccine passports to those on the margins before we implemented vaccine passports. Social justice meant that we needed to balance any harms to people – in terms of increasing the difficulty of accessing bathrooms or warm spaces – with the benefits for those folks. And thirdly, we needed to talk to them and stop just asking the richest in society.
In Ontario, there’s legislation that typically requires that, before we implement policies, we perform a Health Equity Impact Assessment and give thought to how we are going to affect folks on the margins and the ways in which we are trying to accommodate these communities. Vaccine passports requiring identification just happened so quickly that none of that was put in place, and it was really just best designed for those who are already least at risk for COVID – rich people who mostly work remotely and who are all vaccinated, have identification, and smartphones. For some folks, the more restrictions, the more shutdowns, the better – as long as they can still order takeout from home and use Amazon.
Equity is also fundamental to Canadian society. Vaccine certificates are very popular right now, but I worry about making sort of populist decisions because it starts feeling like we’re deviating from what makes us Canadian. Most people might not like a lot of things we do to support the folks that I work with who have histories of substance use or mental health issues, but nonetheless from a public-health perspective and social-justice perspective, it’s critical.
What arguments in favour of the vaccine certificate are most persuasive to you? Where do you feel the most torn in your position?
The general arguments are if we use these mandates, it pushes folks into getting vaccinated. And then secondly, it reinforces the protection of indoor spaces. They’re both great arguments. I appreciate that creating additional pressures for people to get vaccinated is going to increase coverage in this province and will hopefully help us avoid shutdowns in our health-care system and broader restrictive measures. That said, I don’t think we’ve seen a huge number of increases.
As for the second argument often used about the protection of indoor spaces, I think that’s fine. I will note that your vaccine protects you really well, but nonetheless, there remain immunocompromised folks in those spaces and younger children who remain unvaccinated.
As you note, one of the main arguments in favour of vaccine certificates is that they could create safer indoor spaces. Enabling those who are medically vulnerable, such as the immunocompromised, to safely enter indoor spaces is also an accessibility and equity issue. How are you weighing this accessibility and equity issue against the other ones you brought up?
It’s really complex, right? Have the mandates created safer indoor spaces? I’m not sure that’s the case. Maybe for the folks sitting in a fancy restaurant.
I will note that the vaccines are doing amazingly well in terms of protection from symptomatic and especially severe COVID-19, but if you’re really going to create a safe society, there’s a broader range of supportive measures we need to put in place that doesn’t include mandates and certificates.
For some folks, the more restrictions, the more shutdowns, the better – as long as they can still order takeout and use Amazon.
I also worry about moving down that road. Where does it end? Why wouldn’t we then have flu vaccine mandates? I’m confused about COVID exceptionalism. Safety in the way that we’ve defined it here has taken some sort of absolute form.
How do you respond to the argument that vaccine passports will increase vaccine uptake, thereby helping reduce the chance that our ICUs and hospitals will be overburdened and that we’ll need another lockdown?
I don’t think we get that much additional uptake as a result of this somewhat forced measure. There was this announcement when the passport went into place that there was this huge bump in coverage. But I was looking at the charts of the first doses that were administered, and when you have a policy shift, you should see a sharp spike in what you’re measuring, the first doses – but it’s just kind of followed a steady trajectory of increasing coverage over time. The number has just been increasing because we continue to deliver first doses. So, I think it’s a fair question to ask how effective it is – and I don’t want a media release.
What would you say to those who argue that the vaccine certificates are also beneficial because they nudge people into keeping themselves safe from COVID-19 by getting vaccinated?
There was a lot more work to be done in outreach and in meeting the needs of the marginalized before we started punishing people for not being vaccinated. As somebody who leads a team that is vaccinating every day, the stories for why we’re still delivering first doses to folks are diverse. They’re not just a bunch of anti-vaxxers or Trump lovers. These folks have complex questions. Sometimes there is government mistrust or medical mistrust secondary to structural racism that takes time to work through. While a mandate may overcome some of this, doing the hard work of building trust remains central with historically marginalized communities.
In medicine, it is extremely rare that we implement clinical interventions that are against the will of the patient, and so now I’m experiencing really interesting dynamics that are new to me as a clinician. For example, I have to get consent before I vaccinate. So, the other day, I asked somebody I was about to vaccinate, “Do you consent?” He said, “I don’t consent.” I told him, “I can’t provide you the vaccine. It’s totally your choice.” And he responded, “But is it my choice?”
As someone who wants to spend my life as a public-health practitioner, I worry about the relationship that public health will have with the public for decades moving forward. It challenges what this relationship with marginalized communities will be like for other things, like helping them with their hypertension, cancer screening, or mental health. I worry that we’ve reinforced a very forceful way of addressing public health issues. I want to make sure that public health is remembered as a service that addresses unmet needs and is empowering, and is not like the police.