Stefan Baral

We need to better understand vaccine hesitancy:

  • Our team has delivered thousands of doses to marginalized communities across the GTA and the staff that serve them. The reasons that people provide for being concerned about vaccines are complex and nuanced: historical mistrust; had confirmed COVID infections and concerned about side effects; needle phobias; feeling pressured with limited agency to have input to the process.
  • Staff worked in person throughout the pandemic and feel now that they are being fired when they worked through the worst of it without any protection.

Data-based reasons for disagreeing with vaccine mandates:

  • Among facility-based employees, there have been clear intersections with social determinants of health. Specifically, workers at long-term care facilities are more economically marginalized and have had higher burdens of COVID-19. These folks often live in more affected and more economically marginalized parts of the city as well. Ultimately, vaccine mandates among health-care workers are part of the “visible intervention bias” – i.e., it looks decisive but it’s not responsive to the socioeconomic inequities (i.e., the living and working conditions) that have been such consistent drivers of COVID-19.
  • Hospital outbreaks have happened but were generally limited given the hard work of IPAC teams and significant safety measures including enhanced symptom-screening, testing, and masks.
    • Other non-facility-based health-care workers have had risks consistent with the communities in which they live, reinforcing the impact of the IPAC approaches used to protect health-care workers and their patients.
    • No literature of staff-to-client infections – nosocomial cases have been person to person in shared rooms. A more important structural piece to fix in the long term is consideration in new builds.

Vaccine mandates are a passive strategy:

  • Working with staff to look at joint solutions that meet their needs would represent a more active strategy.
    • Are there resources that could be provided, including additional days of paid leave?
    • Are there other concerns that could be addressed with a program or other supports?
    • As noted by Dr. McGreer, are there alternatives that would give people more agency in this decision-making process.

When we deviate from the fundamental principles of public health, we lose trust:

  • In closing, after SARS, one of the things that came across really clearly in the Naylor report were the three underlying principles of public health: 
    • Equity: we do more for people who need more;
    • Participation: we work with communities to develop programs and not for communities;
    • Social justice: we aim to balance the intervention benefit and burden at an individual and community level.
  • With those principles in mind, I would have worked with staff that remain concerned to try and see if there are options including testing, longer unpaid leave, continued masking, exclusion from certain positions, and beyond, to maximize safety and well-being of staff. I believe that was achievable and would have improved longer-term relationships. But I am increasingly concerned that the relationship between public health and its primary consumer has been harmed. Ultimately, it takes a very long time to build trust. But just a single ill-conceived policy to break it. Let’s move away from populist public health and towards empiric and empowering approaches.

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Stefan Baral


Stefan Baral is the director of the Key Populations Program at the Center for Public Health and Human Rights at the Johns Hopkins Bloomberg School of Public Health. With the Inner City Health Associates (ICHA), Stefan co-led the development of an isolation and recovery site for people experiencing homelessness in Toronto. He has also helped support infection prevention and control and outbreak management at shelters throughout COVID-19 and more recently has led the ICHA COVID-19 vaccination team. Stefan has co-authored more than 15 peer-reviewed manuscripts related to COVID-19 that can be seen here.

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