Editor’s Note: Dr. Tom Frieden, director of the CDC from 2009-2017, oversaw responses to the H1N1 influenza, Ebola and Zika epidemics, is President and CEO of Resolve to Save Lives, an initiative of Vital Strategies and Senior Fellow for Global Health at the Council on Foreign Relations.
We are witnessing the Great Unmasking, with masks mandates falling faster, even, than plummeting Omicron caseloads. Dozens of states are removing the power to mandate from public health agencies and governors. Forcing people to do something is an extreme measure; opposition to mask, vaccination, and social distancing mandates is understandable. When are mandates justified?
Public health mandates have three distinct roles: increasing availability of accurate information; protecting people from each other; and establishing collective action that benefits society in ways individual actions cannot. Mandates reflect, and, ideally, strengthen understanding that we are connected: individuals affect and are affected by the actions of others.
Public attitudes toward mandates have shifted as understanding of how behavior can harm others has increased – for example, with laws against drunk driving or establishing smoke-free public places. These changes did not require radical changes to society but were a natural evolution as we better understood these threats and the interventions to counter them.
Omicron has muddled the case for Covid mandates. If vaccination essentially eliminates the risk of spreading disease – as with two doses of the measles vaccine – the case for a mandate is clear. If the burden of a mandate, such as handwashing for restaurant workers, is minimal, then controversy is minimal. And if the risk to others is substantial, as from a person with infectious multidrug-resistant tuberculosis, then compulsory isolation is generally accepted. Omicron is a middle case. It is far less likely to cause hospitalization and death than prior variants, and breakthrough infections among those vaccinated are far more common. But Omicron is so highly infectious that even a lower risk of severe illness still means that hospitalizations and deaths increased. A disease that is both less severe and kills more people complicates policy-making and public understanding.
What’s the justification for mandates for Covid vaccination? Vaccine mandates address both protection from others and collective action to benefit society. Vaccinated people as well as vulnerable individuals are better protected. Society benefits from lower risk of cases, outbreaks, and disruptions of health care, education, and economic activity. The risk from mRNA vaccination is vanishingly small, and these vaccines are highly effective at reducing the risk of severe illness and death.
The case for vaccine mandates for health care workers is clear, as it has been for many years for influenza vaccination. Health workers care for the most vulnerable people in our society. Anyone who goes to a health care facility has a reasonable expectation that the facility will take all sensible steps to avoid causing them harm. And health care workers have a right to be protected, and to have their families protected, from avoidable infection. “Less severe” does not mean “harmless,” particularly for vulnerable populations seeking health services.
When pediatric vaccinations are fully licensed, there will be a case for vaccine mandates for school attendance, as have existed for many vaccines for decades. If Delta returns – or a new variant as or more deadly than Delta emerges – the case for mandates would be much stronger.
The case for vaccine mandates beyond the health care and school contexts is less clear cut. What about people who work or live in correctional facilities? Homeless shelters? In workplaces, protection of coworkers, prevention of disruption, lower healthcare costs, and creating an environment in which people who have medical vulnerabilities are better protected are reasonable considerations that support employer mandates.
We need to acknowledge complexity, values, and the importance of open discussion of mandates. Does a mandate serve the interests of society so much that it justifies compelling individuals or organizations (including private businesses) to do something? Mandates will be effective if there is widespread understanding and acceptance of their necessity.
What about mask mandates? On one hand, requiring someone to wear a mask is far less intrusive than requiring them to receive an injection of a vaccine. On the other hand, there are harms to masking, including discomfort, loss of social connectedness, and cost.
A philosophical underpinning of mandates is the simple concept that your right to swing your fist ends at someone else’s nose. When a deadly variant of Covid is spreading widely, mask mandates in public places are clearly justifiable. The burden of masking is low relative to the burden of severe illness or death from Covid. When both the lethality of Covid decreases – as with the Omicron variant – and the rate of infection decreases – decreasing the risk that hospitals will be stressed and care of patients with Covid and other conditions will suffer – the case for mask mandates is much weaker. In schools, mask mandates when Covid is spreading widely may be an effective means to keep kids in school, teachers healthy, and schools open for in-person instruction.
The goal is to find a balance: When is a requirement on some people justified in order to protect others?
Short of mandates, there is much society can do to protect people. Better information with up-to-date data dashboards and maps that display the equivalent of how hard it’s raining Covid in a community empower individuals to know when they might want to voluntarily increase or decrease their exposures, mask up, or switch to an N95 mask. Employers may choose to offer N95 masks to employees who wish to use them and can promote a culture in which there is no stigma to wearing a mask at any time. Organizations can establish plans for what they will do when there are cases or clusters. Insurers and employers may decide to charge less for health coverage to people who are up-t0-date on their vaccines so that those who are vaccinated do not have the burden of paying for the care of those who choose not to get vaccinated.
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Some mandates are clearly indicated, but when and which is a societal decision, best made with open discussion, weighing scientific facts – including on the efficacy and safety of vaccines and masks – with societal values. Different communities may come to different decisions when faced with similar scientific information. At a minimum, governments should ensure that factual information is timely, widely available, and trusted; communicate the science and rationale for recommendations clearly; and facilitate open, respectful discourse. Recommendations for mandates should be explicit and realistic about both the benefit of any mandate and the burden on those mandated to change their behavior.
