COVID-19 vaccinations reduce our risk of infection, hospitalization, and death. It is heartening that 85 per cent of Ontarians aged 12 and up (75 per cent of the population) have received their first dose.
With rising case counts and the highly transmissible Delta variant gaining traction in Ontario, there is increased urgency to ensure as many Ontarians as possible are vaccinated and that COVID-19 transmission is reduced. A move towards this includes numerous calls for proof of vaccination requirements in public settings.
On September 1, 2021, the Government of Ontario announced they would put regulations in place requiring “Proof of Vaccination in Select Settings.” Beginning today, Ontarians seeking to patronize venues including restaurants, bars, nightclubs, convention centres, sporting events, and concerts will have to show identification along with their “proof of vaccination.” This means either a paper or PDF receipt accessed through Ontario’s provincial booking portal – though the requirement will not apply to staff working in these settings.
The government’s rationale for this proposal is that it may:
- encourage vaccination;
- reduce the likelihood businesses will have to close or have their capacity reduced;
- reduce public health risk for those accessing these venues.
No official evidence appears to have been presented demonstrating to the public whether this approach is the most effective, least restrictive, or whether equity impacts were assessed. If the provincial government has assessed this measure against others, and has undertaken an equity impact analysis, these should be made public. If benefit and equity impact analyses have not been completed, they should be done immediately, and shared publicly.
Are proof of vaccination requirements effective and equitable?
As these requirements are new, there is no direct scientific evidence that vaccination certificates will decrease COVID-19 transmission or increase vaccination rates. Proof of vaccination requirements in other countries have led to increases in daily vaccinations; however, some of those countries had much lower rates of vaccination population-wide (such as France, which was around 55 per cent of population at the time). Therefore, we may not be able to expect similar levels of success in Ontario, where the general rate is relatively high, but where certain populations have rates that are much lower.
In July, Ontario’s Science Table said that this approach could, in theory, help, but also said that the government needs to seriously address equity, access, and discrimination issues if they develop and rollout vaccination proof requirements and ensure that proof of vaccination documents are “made available in a way that is equitable and accessible to everyone.”
Wellesley Institute’s recent report on vaccine hesitancy assessed the effectiveness and equity impacts of vaccination requirements. The report found that vaccination requirements might negatively impact confidence in vaccination by undermining public trust in policy makers, but were likely to positively impact unvaccinated individuals’ complacency by increasing the perceived need to get vaccinated (due to restrictions for unvaccinated individuals).
It raised several equity questions and concerns:
1. Will efforts be taken to ensure that everyone has meaningful access to the vaccine and have their questions about vaccines answered?
- Proof of vaccination requirements do nothing to address systemic barriers to vaccine access or lack of trust or information about the vaccine. Both of these factors could improve vaccine uptake while enhancing equity.
- Requirements could further exclude those already facing barriers to vaccination, and further marginalize people who are homeless, migrants and undocumented people without health cards or valid identification, and/or anyone facing barriers to obtaining and keeping identification and documents.
2. Will everyone who got vaccinated be able to easily prove they did? Will individuals requiring medical exemptions be able to easily prove they did?
- Individuals without valid identification or health card numbers would have difficulty accessing proof of vaccination, and concerns were raised around what would happen to individuals with legitimate medical exemptions.
3. Who would enforce these rules?
- These requirements have the potential to be differentially applied and enforced in ways that target Black, Indigenous, and other racialized Ontarians.
Have equity issues been considered by government?
The government has indicated awareness of some of these issues, however, has not demonstrated that there is a plan to address them.
For people without smartphones, health card numbers, printers, and identification, the government’s Frequently Asked Questions page for the new Proof of Vaccination requirement states that it will provide “alternative tools for people with no email, health card, or ID,” but gives no timeline. This means that by the time of launch, some vaccinated people in Ontario will be unable to prove they have been vaccinated – this is not fair or equitable.
Those with valid medical exemptions are expected to provide a doctor’s note. The College of Physicians and Surgeons of Ontario has provided guidance on which exemptions will qualify, and the government has indicated it will offer additional information.
Regarding enforcement, the government has explained that Ministry of Labour, Training and Skills Development inspectors will offer education and warnings, but that the rules will eventually be enforced by bylaw officers. Fines are similar to existing penalties for COVID-19 rule violations.
What still needs to be done?
There are crucial further steps the government could, and should take, to ensure harmful impacts on certain groups are reduced as much as possible.
First, the government must continue to expand its efforts to overcome barriers to vaccination. It is of note that some racialized populations, such as the Black populations of Ontario, are two times more likely to be unvaccinated and at four times greater risk of getting COVID-19. The failure to eliminate racial and other vaccination rate gaps before introducing proof of vaccination will exacerbate inequities. A concerted effort to achieve vaccination equity may be the most effective way forward.
The government should consult with experts and those with lived experience, to put forward a robust, funded plan as soon as possible. Significant community efforts have been put into making it possible for people who are homeless, do not have access to technology, do not have a health card number or ID, to be vaccinated at lower barrier clinics. However, the failure to ensure that solutions are in place for these populations before proof of vaccination is required raises significant equality rights concerns, along with the risk of further marginalization.
Documentation for people who are medically ineligible for the vaccination must be easy to access and use. Carrying a doctor’s note around requires individuals to provide business operators with personal health information. Further, primary care access has been reduced due to the pandemic, and this has likely only exacerbated access issues for those with no primary care provider. The government should ensure that individuals who are medically unable to be vaccinated are able to seamlessly obtain a note from a primary care provider free of cost. This would ensure human rights are equally protected for those with these disabilities.
The government should consult with groups representing racialized individuals, as well as civil liberties and poverty advocates, persons with lived experience, and experts, to mitigate the potential damage that could come from decisions to call police, and actions of police in enforcing this new rule against alleged trespass or threats. Enforcement continues to raise very significant concerns but nothing has been released by the Government of Ontario to suggest this time will be any different. Additionally, businesses’ denial of service to people who are not fully vaccinated or cannot prove their vaccination status is likely to create its own problems. Attempts by businesses to deny service will likely lead to conflicts and although the Ontario Association of Chiefs of Police have indicated the government has confirmed police will not “be expected to conduct routine compliance checks,” the government’s Solicitor General has already urged businesses to call 911 when they occur.
If police are to be involved, Police Service Boards should set clear policies regarding vaccination proof enforcement, and consult with communities, to mitigate the risks. Enforcement should also be carefully monitored, with results made publicly available. To reduce friction and confusion that may lead to police calls, the government should launch a significant education campaign, with multi-lingual materials and community-based outreach, to explain these changes.
Creating healthy policy is a process. While the government has factored in some equity concerns, there is much more to do in order to avoid further damage to equity-seeking individuals in Ontario. More needs to be done urgently, given the extremely short timeline given for the introduction of this new policy.