How to deal with the unvaccinated? There are four options

Much of the world continues to grapple with the COVID vaccine dilemma. With data showing that vaccines significantly reduce the case fatality rate of COVID to around 0.3% and, at the same time, vaccines also proving far less effective at stopping transmission of the virus courtesy of the Delta variant, there is — dare I say it — some sort of argument on both sides.

All this is happening against the backdrop of a northern hemisphere winter which will inevitably lead to a significant jump in the transmission of respiratory viruses — and COVID remains the only game in town.

Governments essentially have four choices. One: impose soft restrictions (such as travel) on those who are unvaccinated — this is the UK and, until recently, European approach. Two: fully mandate vaccines, like Austria, or quasi-mandate them by removing most freedoms like in Victoria or France. Three: impose some sort of financial penalty on the unvaccinated, an approach taken up in Singapore and suggested by health economist Luke Slawomirski in Crikey last week. Or four: do nothing other than providing free vaccinations and educating people as to their benefits, as seen in eastern and southern European countries like Croatia.

Let’s focus on the two more controversial approaches: mandates and financial penalties. While enticing, both methods have significant drawbacks.

Vaccine mandates aren’t novel. In Australia, the “no jab, no play” mandate requires children in Australia (the campaign was actually spurred by News Corp newspapers in 2013) to be vaccinated to attend child care or kindergarten.

The rationale for the mandate makes sense because children could potentially contract a lethal measles infection at pre-school before they even had a chance to be vaccinated. The problem though, as Guardian Australia noted, was that the policy didn’t seem to have a material impact, with a Medical Journal of Australia study finding that “there was just no major change to that vaccine-objector group with the ‘no jab, no play’ policy … but on the positive side, a substantial number of people did catch up vaccination which led to modest increases in overall vaccine coverage”.

Bear in mind that kids are genuinely at risk of death from measles or mumps, whereas the fatality rate of COVID for those who are not elderly or suffer significant comorbidities remains infinitesimally small.

Then there’s the issue of enforcement — the “no jab no play” rules are monetary (so technically fit in the third category). The moves by Austria to forcibly vaccinate people or by Victoria to essentially give people the choice between vaccination and unemployment are a far greater step.

It remains to be seen exactly how a mandatory vaccination can occur without the serious threat of imprisonment, which, given vaccines mainly protect the taker from serious illness, make little sense. Moreover, it is likely to lead to significant civil unrest, already playing out to some degree. There’s also the problem that if 20% of a population refuses to take a vaccine, it’s simply impossible to imprison that many people (and there’s likely to be a full-blown revolution before that point).

Then there’s the financial route, which Singapore is adopting. This has its own set of issues. While Singapore, a well-run autocracy with very high levels of government trust, may get away with charging COVID patients for their ICU stay, this is far more difficult for almost every Western nation. There’s also the problem of governments picking which people need to pay for their own treatments. It would make little sense to charge someone for not being vaccinated against COVID but not, say, smoking, when the chances of serious illness from COVID (for a healthy 30-year-old) are likely less than 0.01% compared to 67% of smokers who die from a smoking related illnesses.

The Medicare levy surcharge plan, while ostensibly softer than the Singapore method, has even more flaws. Those most at risk from serious COVID illness are the elderly — the exact same cohort who in almost all cases have zero taxable income courtesy of our gerrymandered tax system. A higher Medicare charge will do virtually nothing to reduce COVID-19 deaths or reduce ICU usage. That is because those who will bear most of the cost of a Medicare levy surcharge plan are unvaccinated people aged 25-65 — that is, people who have a very small chance of hospitalisation and a tiny chance of death.

While Australia doesn’t provide this data, England fortunately does. Last week, only six people per 100,000 aged between 25 and 64 were admitted to hospital with COVID in England (despite 35,000 daily reported infections). For those aged over 85 (that is, people who wouldn’t be paying anything because they have no income), the rate is 41 per 100,000.

Bear in mind that’s hospital admissions, not ICU admissions. Only 20% of hospitalised COVID patients need ICU. Plus some of those people in hospital would be vaccinated “breakthrough” cases anyway. So if we use the UK data as a guide, we’re likely looking at, in the worst case, a few thousand ICU admissions a year in Victoria and NSW of non-vaccinated people who actually have had to pay the higher Medicare levy.

It’s likely that the vaccine arguments are soon to be proven moot in any event, with vaccines about to be gazumped by an even better life-saving technology — anti-viral treatments. Three weeks ago, Pfizer announced that its Paxlovid drug was able to reduce deaths in a clinical trial by 89%, when taken 3-5 days after COVID symptoms begin.

Merck had announced a week before that its Molnupiravir drug was around 50% effective in trials, with India expected to give emergency approval within days. These (not yet peer-reviewed) results are genuinely game-changing and will make COVID less deadly than the influenza even amongst the unvaccinated.  

Forcing people to take a vaccination which they don’t understand (even if it’s largely in their best interests) is unlikely to improve vaccination rates and instead, lead to civil unrest and further fracture communities. So sure, let’s continue to educate and encourage the unvaccinated on the benefits of vaccination. But with the antiviral cavalry coming, threatening imprisonment or imposing a bizarre tax on the unvaccinated is as foolish as a slow vaccine rollout.