COVID-19 vaccination requirements for Ireland's healthcare students

Abstract

International debate on COVID-19 policy issues, notably negative social consequences, is vital when grappling with the pandemic legacy. Drawing from the second author's experiences in the Irish healthcare and higher education sectors, this commentary scrutinises measures that discriminated against students who declined novel COVID-19 pharmaceuticals. In so doing, it serves as a point of contrast to fear-based interventions. Connections are made with relevant literature when urging those in authority to ensure that policies intended to maximise vaccine coverage are seen to be fair and convincing. The commentary concludes with some reflections that could underpin more defensible policymaking and inform future research.

Introduction

International debate on COVID-19 policy issues, notably negative social consequences, is vital when grappling with the pandemic legacy (Briggs et al., 2021; Ioannidis, 2022). For instance, extending some of his reflections on ‘the harms of exaggerated information’ and ‘non-evidence-based measures’ early in the COVID-19 pandemic (Ioannidis, 2020a), Ioannidis (2022: 7) writes: ‘Mandates and measures that discriminate people based on their pandemic-related status (e.g., vaccination record) may be particularly problematic’. Possible problems include ‘fostering divisiveness’ and ‘discord’ (p. 7). Drawing from the second author's experiences, this commentary scrutinises measures that discriminated against healthcare students in Ireland who declined novel COVID-19 pharmaceuticals. Connections are made with relevant literature when urging those in authority to ensure that policies intended to maximise vaccine coverage are seen to be fair and convincing. We conclude with some reflections that could underpin more defensible policymaking and inform future research.

Context and caveats

This commentary emerged from our conversations early in 2022 on how healthcare students, who declined COVID-19 vaccines, were treated as ‘outsiders’ within a broader panoply of restrictive pandemic policies. As Becker (1966) explains, those positioned as ‘outsiders’ are likely to have their own definitions of the situation. Exploring such understandings, we contend, is necessary when learning from the pandemic response. However, before recounting Aoife's experiences in the Irish healthcare and higher education sectors, we will cover some preliminary ground. First, we will outline the specific policy directives pertaining to healthcare students in Irish Higher Education Institutes (HEIs), their COVID-19 vaccination status and clinical placements in Health Service Executive (HSE) facilities (i.e., publicly funded hospitals and other healthcare settings). Second, we will acknowledge the difficulties but necessity of critique as part of a qualified discussion on a polarising issue.

The HSE (the organisation that enacts Department of Health policy) issued instructions on healthcare students’ unpaid clinical placements (a core training requirement) in the context of Ireland's national COVID-19 Vaccination Programme, launched on the 29 December 2020. On the 26 March 2021, the HSE's Office of the Chief Clinical Officer wrote to all HEIs stating that from the 1 April, ‘Students that are eligible for vaccination, that have been offered vaccination and decline vaccination should not be assigned to clinical placements in HSE facilities’ (in Sheils, 2021: Appendix 3). Further correspondence, dated 2 April 2021, from the Clinical Advisor to the COVID-19 Vaccination Programme clarified the HSE's position by underscoring the need to ‘reduce risk to patients and staff’ (in Sheils, 2021: Appendix 3). Both communications indicated the decision might be reviewed. A subsequent directive from the Chief Clinical Officer, dated 12 April 2021, ostensibly superseded earlier instructions (amidst emerging safety concerns about AstraZeneca's product; see also Department of Health, 2021), whilst nonetheless stating clinical placements for all healthcare students ‘may continue in HSE facilities subject to students continuing compliance with public health recommendations and infection prevention and control practice’ (Henry, 2021). Thereafter, healthcare students in various fields (e.g., medicine, nursing, physiotherapy, dentistry) were issued with university-level policies/instructions to avail themselves of COVID-19 vaccinations. Whilst the Dean of the Faculty of Health Sciences, Trinity College Dublin, for instance, framed uptake as a ‘choice’ for responsible students who ‘educate’ themselves on ‘the benefits and risks of COVID-19 vaccinations’ (Sheils, 2021: 3), those who declined risked their careers (Roseingrave, 2022).

As with France's pass sanitaire, policies effectively requiring mass compliance with COVID-19 vaccination programmes seemed to be justified during ‘an emergency’ when people reported feeling ‘scared’ (Drew, 2022: 23). In our view, though, fear, especially if it persists beyond the early stages of a novel infectious disease outbreak, is not a convincing basis for hierarchically imposing (or ‘nudging’ and ‘shoving’ people towards) invasive and potentially iatrogenic interventions. Alongside critical commentary on ‘the weaponisation of fear’ (Dodsworth, 2021) and ‘elements of propaganda’ in Western media, government and public health responses to COVID-19 (Hirsch and Rinner, 2022), issues that concern us include disproportionate control measures based on weak or no evidence, unknowns about long-term drug safety and unfair discrimination. Our critical reading differs from writings on ‘vaccine hesitancy’. Whilst Hirsch and Rinner (2022) reject the ‘psychopathological’ (p. 81) connotations of that term and the implication that compliance is the only valid response, Peretti-Watel et al. (2015) explain that the notion ambiguously conflates various beliefs, attitudes and behaviours. Consequently, it elides heterogenous, context-specific decision-making processes comprising, for example, information-seeking and distrusting particular pharmaceuticals.

A critical approach in this field is admittedly difficult for many reasons. Note, for instance, sociological insights on ‘the cult of public health’, which, like the state, has ‘absolutist tendencies’ (Dew, 2012: 129). Public health has even been described as ‘esurient’, meaning ‘it has a voracious appetite for consuming the social world in its efforts to make all that is around it part of itself’ (p. 141). Such tendencies were amplified after the World Health Organization declared the COVID-19 pandemic in March 2020, with many societies subsequently entering ‘lockdown’ (Briggs et al., 2021). Shortly thereafter, Caduff (2020: 481) observed that we had entered ‘a difficult place for critique’. Notably, critical responses were equated with right-wing politicians lacking social conscience. Yet, the pandemic exposed many issues that warrant scrutiny, notably how fear was ‘fueled by mathematical disease modelling, neoliberal health policies, nervous media reporting, and authoritarian longings’ (p. 467).

When reflecting upon the difficulties of critiquing COVID-19 vaccination policies we would also flag entangled processes of ‘pharmaceutical governance’, that is ‘relations of power and domination’ within which the consumption of pharmaceuticals is embedded (Dew, 2019: 6). Internationally, ‘public health advocates’ have tended to be complacent about the demonisation of vaccine-related concerns, with some even throwing ‘fuel on the fire’ by seeking to restrict critical scholars’ ‘academic freedom’ (Dew and Donovan, 2020: 1). Furthermore, consider how publics were framed during the COVID-19 pandemic as ignorant and/or idiotic, alongside the need for health agencies to downplay their own uncertainty in order to project a sense of authority and expertise (Green et al., 2022). Clearly, then, this is difficult terrain but, as Dew and Donovan (2020) explain when discussing vaccination and polarising divides, it warrants scrutiny since policies intended to maximise vaccine coverage need to be seen to be fair and convincing. Scrutiny is especially apt when those working in healthcare, who cannot so easily be dismissed, reject some pharmaceuticals.

To be clear, then, our commentary is not ‘anti-vaccine’ nor contrary to healthcare providers’ duty to care. On the latter point, healthcare workers have professional and ethical obligations not to harm patients, meaning mandatory vaccinations may, in some instances, be justified (a view taken by Giubilini et al., 2023, but not in relation to COVID-19 based on the existing knowledge base). Nor are we defending what has been called ‘bioprivilege’, wherein those posing a public health risk ‘to the many’ ‘demand’ their ‘personal preferences’ are both ‘officially recognised’ and accommodated by society (Green et al., 2022: 594). Rather, we proffer an ‘appreciative’ rather than ‘correctional’ perspective (Matza, 1969) on why people may question and even reject policies that might otherwise appear justified. Refusal to appreciate such decision making in context is, in our view, not risk free: it could (further) erode trust in authorities promoting vaccines (Yaqub et al., 2014) and jeopardise healthcare delivery. On the latter point, note the risk of exacerbating ‘chronic workplace shortages’, a prospect informing the UK Government's decision to abandon a COVID-19 vaccine mandate for National Health Service staff in early 2022 (lacobucci, 2022).

Experiencing the pandemic and discrimination

Before commencing her General Nursing degree in September 2020, Aoife had worked for ten years as a health care assistant, medical secretary and dental nurse. She was also working in an Irish hospital when the COVID-19 pandemic was declared. During that time, Aoife felt some anxiety. She observed that SARS-CoV-2 (the virus that causes COVID-19) spread rapidly in the hospital among patients and their carers (i.e., nosocomial infection). Many people experienced flu-like symptoms such as coughing, shortness of breath and anosmia. However, despite a high proportion of infections being diagnosed among frontline healthcare workers, Aoife quickly reassessed the risks posed by the virus after learning that none of her colleagues became critically ill and died. A proportion of patients and staff also remained asymptomatic or negative upon nasal swab sampling. Without denying the potential seriousness of COVID-19, especially for older adults with co-morbidities, humanity was evidently not facing an ‘existential threat’ like ‘the Black Death (bubonic plague)’ in the fourteenth century (Dingwall, 2022: 3–4).

In May 2021, Aoife attended her first hospital placement as a nursing student. The national COVID-19 Vaccination Programme had also been underway for several months, with university administrators instructing healthcare students to ‘comply’ because ‘we should protect each other’. That was an almost irresistible call. It not only invoked professional obligations and ethics but also, more broadly, constituted students as ‘good pharmaceuticalised citizens’ (Dew, 2019: 181), or ‘biological citizens’ with ‘renewed obligations to maintain their own and their communities’ health’ (Green et al., 2022: 596). However, Aoife questioned the request after already working on the frontline, providing patient care and likely being exposed to SARS-CoV-2. She reasoned that viral exposure should have caused an innate immune system response and the production of protective antibodies, negating the urgency of taking novel pharmaceuticals (see also Giubilini et al., 2023). She also had apprehensions about the drugs’ safety profiles. There is precedent here, as observed internationally in research on health professionals and vaccination (Yaqub et al., 2014). As intimated above, AstraZeneca's product was also briefly suspended in Europe in early 2021 amidst safety concerns (reports of unusual blood clotting), whilst some countries ceased administering it altogether (Lo Re et al., 2021).

In October 2021, the university cancelled Aoife's next clinical placement. Her presence was deemed ‘unsafe’ for patients, implying that COVID-19 pharmaceuticals provided sterilising immunity against infection and transmission. Whilst Aoife's continued employment as a hospital health care assistant remained unaffected, fear-based expulsion was ubiquitous at this time; people were barred from many public venues if they could not ‘prove’ their vaccination status. However, such discrimination was questionable. As per Foucault's (1978) discussion ‘about the concept of the “dangerous individual” in nineteenth-century legal psychiatry’, authorities were enforcing ‘public hygiene’ on the basis of symbolic representations not ‘scientifically established’ facts (p. 8; see the next section).

In February 2022, against the backdrop of more stringent pandemic policies in other countries, some Irish university administrators mooted the possibility of mandating COVID-19 vaccines for healthcare students. A mandate is ‘the most intrusive and coercive measure’ that might be taken towards those who refuse ‘vaccination’ (Health Information and Quality Authority [HIQA], 2021: 13). Furthermore, as explained by HIQA when addressing Ireland's National Public Health Emergency Team on the treatment of clinical staff, ‘[e]thical commentaries highlight the risk of a breakdown in trust between staff and their institutions if mandatory vaccination is implemented’ (p. 12). During a meeting between Aoife and university administrators, they insisted she should get ‘the vaccine’ because it was ‘a nurse's duty to promote health’ and, by complying, she would demonstrate her professionalism. They also mentioned a ‘fitness to practise inquiry’ (a referral to the Nursing and Midwifery Board of Ireland), with the possibility of being ‘struck off’. Feeling threatened, Aoife contacted her union. However, they merely suggested that she ‘should take the vaccine’. Such responses further demarcated ‘insiders’ from ‘outsiders’, the ‘safe’ from the ‘dangerous’, the ‘virtuous’ from the ‘deviant’, the ‘sacred’ from the ‘profane’, those deserving and undeserving of support.

In response to changing ‘epidemiological data’ intimating a ‘broadly positive outlook’ (Houses of the Oireachtas, 2022), the Irish Government dropped many of its COVID-19 restrictions in February 2022. The HSE also issued ‘Guidance on Clinical Placements’, effective from 1 March 2022, removing (most) discriminatory measures against students who declined COVID-19 vaccinations whilst (questionably) framing past organisational directives as reasonable in challenging times. On the 8 March, Aoife went on clinical placement as a nursing student. Like other healthcare students in Ireland (Roseingrave, 2022), she had suffered a bruising experience and it is one which, based on clinical literature published between 2020 and early 2022, seems difficult to justify. We will briefly mention seven points, which arguably could have informed a more defensible approach.

Evaluating exclusionary practices in the COVID-19 era

First, ‘lay epidemiological knowledge’ about COVID-19, rather than irrationally minimising danger, may align with what was reported in the scientific literature. Notably, towards the end of 2020, Ioannidis (2020b) inferred from 82 seroprevalence study estimates (mainly from locations hardest hit by the pandemic) a median global infection fatality rate of between 0.15 to 0.2 per cent (0.03 to 0.04 per cent for those under 70 years of age). Restated, mortality risk was likely to be low, deduced not from ‘erroneous modelling assumptions’ (p. 4) but rather from researchers’ efforts to ascertain the prevalence of SARS-CoV-2 in sampled populations via blood analysis and detecting antibodies following viral infection. Second, the pivotal COVID-19 vaccine trials were never designed to provide data on effectiveness against infection and transmission of SARS-CoV-2 (Doshi, 2020); hence, discriminating against healthcare students because of their vaccination status, allegedly to protect patients and staff, was not evidence based. Third, continuing to exclude a small minority of students in late 2021, for declining novel pharmaceuticals, became increasingly questionable following evidence that nosocomial outbreaks of the Delta variant of SARS-CoV-2 could still occur among twice vaccinated and masked individuals (Shitrit et al., 2021). Fourth, advocating mRNA COVID-19 vaccines, because they provide excellent self-protection (>90 per cent), neglected the ethical principle of informed consent — a problem attributable to ‘outcome reporting bias’ since claims for high efficacy were based on relative, not absolute, risk reduction (Brown, 2021). Fifth, mass COVID-19 vaccination proceeded despite ‘many remaining unknowns about safety’ and insufficient scientific evidence that ‘clinical benefits outweigh risks for all populations’ (Wastila et al., 2021). Sixth, those pushing for compliance in the healthcare and education sectors might have reconsidered their actions in view of writings on care home workers in England, where legislative changes mandating vaccination were deemed ‘unnecessary, disproportionate and misguided’ (Hayes and Pollock, 2021). Seventh, ‘errors’ from a previous pandemic were repeated, including the lack of transparency within ‘big pharma’, which is ‘the least trusted industry’ (Doshi et al., 2022).

Final thoughts: Towards defensible policymaking?

As societies transition to COVID-19 endemicity, policymakers in Ireland and elsewhere may have to contend with the intensification of problems such as burnout, disillusionment and moral distress among healthcare professionals and those in training. Despite policies intended to protect health systems and the most vulnerable, including mandating COVID-19 injections in various nations and locations (Giubilini et al., 2023), likely implications for patients include encountering a depleted workforce that is unable to deliver optimal care.

Given such consequential matters, it is worth recognising that sociologists offered useful yet largely ignored insights for pandemic policymaking before COVID-19 and throughout this debacle. For instance, it was known that corrosive social responses (e.g., fear, panic, stigma) typically accompany novel infectious diseases in ways that can be far more contagious and damaging than biological pathogens (Strong, 1990). A wider appreciation of such insights could potentially have informed a more proportionate and less harmful approach to COVID-19 policymaking, especially after the initial viral outbreak when it was known humanity was not doomed. Furthermore, although vaccination is a polarising issue, it was known that even ‘radical’ groups who challenge vaccination policy align with ‘broader cultural attitudes’ and ‘new public health’ imperatives (e.g., becoming informed, taking responsibility for one's health, making choices) (Hobson-West, 2007: 211). What we take from such literature is that if ‘personal privacy and liberty’ are to be ‘seriously invaded’ by pandemic ‘control measures’ (Strong, 1990: 254) then such action, rather than being an imposed response to a protracted (weaponised) ‘state of fear’ (Dodsworth, 2021), must be revisable and justifiable with respect to entrenched social values (e.g., the ability to experience a meaningful life with others, obtain a decent education). We would add that the common refrain to ‘follow the science’ is an inadequate defence for those seeking to justify invasive health policies and retain or restore ‘faith in conventional authority’ (Strong, 1990: 257). That refrain begs questions that were posed by sociologists when scrutinising earlier COVID-19 control measures. For instance, ‘which science’ (Dingwall, 2022: 7); what is the current state of scientific knowledge, and, concerning the ‘science-policy interface’, is there ‘interdisciplinary integration’ and success in incorporating ‘insights of the full range of relevant experts and affected stakeholders’ (Martin et al., 2020: 501)? More recently, Pykett et al. (2022) dismiss the idea of ‘science to the rescue’ when asserting that ethical moments in pandemic policymaking necessitate democratic debate.

Hopefully our commentary underscores the need for inclusive dialogue and defensible policymaking on an issue that exceeds Aoife's experiences and Ireland's relatively ‘soft’ approach to COVID-19 vaccination status. Admittedly, eschewing a correctional stance will likely irk ‘converts’ (Strong, 1990) to the COVID-19 crusade, incorporating powerful modes of entrepreneurship and public health rituals promising salvation through moral regulation. Critical scholars, who have advanced insights not only on pharmaceuticalised governance but also public health as esurient, understand the ‘taboo reaction’ (Dew, 2012: 121) evinced when sacred health knowledges are questioned. Nonetheless, when learning from recent events we favour open space for critical scholars to work with clinicians, students and others who might otherwise be demonised or ignored within relations of power and domination. Cultivating such space, we believe, is necessary if authorities aim to renew or bolster public trust.

Yet the issue of trust could be thorny for many reasons that include, but are not confined to, COVID-19 vaccination requirements. Consider three brief points. First, there was the ‘warp speed’ development of COVID-19 pharmaceuticals and state-backed calls to take these in order to participate in society. Such developments and responses may have been welcomed by many people wishing to ‘regain their freedoms’, exemplifying ‘pharmaceutical citizenship’ (Dew, 2019: 157). However, granting full regulatory approval for (let alone requiring or mandating the use of) novel mRNA pharmaceuticals might have been premature and it could backfire (Wastila et al., 2021). Second, questions surround the track records, ethics and credibility of authorities that are in the business of declaring and ‘solving’ global health crises. Many documented problems within public health, allied sciences and policymaking pre-dated the COVID-19 pandemic response but they subsequently became entangled with it (e.g., presumptions, myths, prejudices, uncorrected mistakes) (Monaghan et al., 2022). Third, general structural features of high modernity — increasing specialisation, the disembedding of institutions, the leap of faith required in expertise — render ongoing contestation likely. Peretti-Watel et al. (2015), for instance, theorise what they term ‘rationalised vaccine hesitancy’ (notably among educated middle-classes) as a consequence of these macro-social structures. The organising principles, rules and resources of high modernity elevate the importance of and uncertainties surrounding manufactured risks, health and trust in abstract systems. An alternative reading is that populations have repeatedly experienced (and possibly understand, at some level) ‘shock doctrine’ responses to crises, with COVID-19 again enabling ‘disaster capitalists’ to benefit massively at public expense (Klein, 2020).

There is much to consider and reasons to work ‘toward another politics of life’ (Caduff, 2020: 479) comprising greater equity, respect and ethical deliberation. Indeed, insofar as COVID-19 boosters continued to be mandated, notably in North American universities when we were finalising this commentary, we would urge administrators to engage with mounting arguments against such policies (e.g., Bardosh et al., 2022) along with line managers, employers, unions and students. Also, if ensuring broader public faith in pandemic policies is on the agenda then practical steps might include health authorities devising an ‘agile internationally harmonised’ pharmacovigilance system (Lo Re et al., 2021), and advocating for decent compensation mechanisms for the vaccine injured and bereaved. Critically, though, ‘trust as faith’ may itself be ‘a source of risk’ for those publics who remain passive and deferential to established authorities, rather than active agents who navigate myriad contradictions, information sources and ‘powerful discourses’ (Hobson-West, 2007: 212).

Finally, international research is urgently needed as publics, including (future) clinicians, reflect upon and perhaps continue to struggle with ‘the social harms of pandemic mismanagement’ (Briggs et al., 2021). Such research might explore matters ranging from scapegoating and the forms of distress associated with COVID-19 control measures to how ‘pandemic psychology’ (Monaghan, 2020), ‘the rise of authoritarianism’ (Simandan et al., 2023) and pharmaceuticalisation are entangled with the fundamental causes of health inequalities. Crucially, when undertaking such research we would also emphasise critical social policy analysis, and, in so doing, interrogate discriminatory state-backed responses that risk fuelling ongoing divisiveness and discord in these already troubling times.