By Ruth Rodney
Dr. Ruth Rodney is Assistant Professor in the Faculty of Nursing at York University, Canada. She is also a registered nurse.
In the first week of August, I began seeing reports on Facebook about vaccines becoming mandatory in Guyana. At first, I did not pay much attention. Mandatory vaccines have been a topic of discussion globally, specifically with regard to travel and how countries would navigate the opening of borders. In recent months there have been reports of vaccine requirements to participate in some public events or to dine in restaurants across the United States. In the past weeks mandatory requirements have extended to university campuses, federal workplaces, and healthcare facilities in Canada. Vaccination mandates are steadily increasing. Most recently, many workplaces including hospitals and police stations have announced that if workers continue to refuse to be vaccinated by October 2021, they may lose their jobs. These recent changes have been in response to fears surrounding the fourth wave of Covid-19 in Canada, and come after an expansive vaccination strategy that spanned more than 6 months, led by the federal and provincial governments. I make these points to highlight that the conversation about vaccinations and whether they should be mandatory is not specific to Guyana. However, enforcing mandatory vaccinations to access health care and other essential services in less than a month is where Guyana has set a concerning precedent, one that moreover may not deliver the expected results but instead create more difficulties.
At the end of July, Guyanese residents were informed by the Ministry of Health that ID and vaccination cards would be required to access Government agencies. Just a few days later, on August 1, notices began appearing from various agencies that vaccination cards would be required. Notably, on August 6, the Guyana Public Hospital Corporation (GPHC) released a public advisory notice indicating that, ‘effective immediately’, all persons requiring access to the hospital and/or ancillary clinics would require proof of vaccination. The advisory further stated that individuals without proof of vaccination would be required to book an appointment and present a negative PCR test from a Ministry of Health approved testing centre within 72 hours of the appointment date. Although the announcement indicated that the vaccination mandate did not include those persons requiring emergency medical treatment, in the days following these notices reports surfaced of people being turned away from hospitals, including pregnant women.
In my 17-year career as a registered nurse, I have also had the privilege and honour of nursing alongside GPHC Accident and Emergency staff in the early 2000s. While I reflect on this current approach from my professional viewpoint, my concerns also arise from my personal connections to Guyana. I have family members who work in the health care sector and others who must access it as their only choice. It is my worry for their safety and wellbeing, as well as Guyanese and others resident in Guyana, that has me thinking about the complications of creating further barriers to access essential services in the middle of a pandemic. One of the very real issues of this approach is that while it seeks to decrease the spread of the virus, it creates a slippery slope of determining who deserves access to care, which may result in delayed diagnosis and treatment of the very disease we are trying not to spread. While I understand and appreciate the urgency of curtailing the spread of Covid-19, an approach that has the danger of appearing to be a strong-arm response leaves more people increasingly vulnerable and has the potential to cripple an already fragile healthcare system.
One of the major challenges facing many countries, including Guyana, is vaccine hesitancy. Mandating vaccines in the manner that was chosen may not dispel this – if anything, so far it seems to have made vaccine hesitancy in some communities worse and also seems to be leading to the creation of false vaccination cards. Minister of Health Dr. Frank Anthony indicated that Regions 8 and 10 have the lowest vaccination uptake in Guyana. The recent protests in support of unvaccinated healthcare workers locked out of the Linden Hospital Complex, suggest that Region 10 may continue to struggle with vaccine uptake if the approach is not modified. Further, the protests last week at GPHC show that vaccine hesitancy may be more widespread across the country.
We need to contextualise levels of skepticism about a new vaccine; again this is not confined to Guyana, given wider histories of racism in relation to communities that were targeted for medical research and experimentation (just a few examples are the Tuskegee syphilis experiments that used African-American men, or contraceptive experimentation with women in countries like Mexico, Puerto Rico, Bangladesh). Another driver of vaccine hesitancy is the overabundance of accessible information on vaccines; in fact we might refer to a good deal of this as accessible misinformation since it is not always accurate or backed by science. There is also the ever-growing anti-vaccination movement that has linked autism and mercury content to vaccines. To be sure, social media has provided platforms that are useful in sharing information, but can also be dangerous for a public health crisis when personal opinions become fact or when inaccurate comments gain traction. The comment sections under Guyanese journalist Gordon Moseley’s Facebook news page provide important insight into the varied perspectives and understanding of Covid-19 vaccinations. The comments and questions point more toward vaccine hesitancy than an anti-vaccination rhetoric. They offer important information that can be used as one kind of marker to gauge vaccine knowledge in the general public. It can also provide key areas where public health efforts can be focused, potentially improving confidence and safety in vaccines, with less chance of compromising trust between the general public and elected officials. A comprehensive approach to addressing vaccine hesitancy would be to engage with communities to understand their specific concerns regarding the vaccine, directly answer their questions, and continuously counteract inaccurate information with accessible public health campaigns that unfold on the ground and with as many local partners as possible who clearly have the trust of the specific communities being visited.
Secondly, while the pandemic recovery will require a multi-faceted approach, health care providers, including allied services within hospitals remain an essential resource in dealing with this pandemic effectively. We want workers to be as safe as possible, especially when they are on the frontlines caring for patients. However, if health care workers choose to remain unvaccinated, as seems to be the case, it means that further work is required to understand and address their concerns. Here again, Guyana is not the only country that has grappled with a hesitation among health care providers – yet the difference once again lies in the approach. To my knowledge, this is the only country to date that has locked health care workers out of hospitals and with such short notice. In response to widespread critique and protests, the Ministry of Health extended the period to obtain a vaccine by two weeks. However, this decision is not one that addresses the root causes of vaccine hesitancy amongst health care workers and the danger is that it will only create further tensions that may undoubtedly drive some workers out of a sector that is already grossly understaffed. What does this mean for the average Guyanese citizen who relies on health care within the country?
As I stated earlier, early reports surfaced that some pregnant women were turned away from receiving care, and in response the rules were changed. Yet, women and unborn children were still put at risk unnecessarily. Moreover, if communication for the change in rules has not been coordinated, it means that some places may still deny women care based on a now defunct rule. We also need to consider the inconvenience and economic costs of traveling to medical appointments, potentially losing time at work, only to be turned away. Who then compensates these women?
The pandemic has also taught us that public health measures can increase the risk of violence for women and girls in intimate relationships. Asking people to make an appointment to access healthcare services in a hospital, which also includes an additional step of obtaining a PCR test, does not adequately consider the vulnerable situations that victims of violence are forced to contend with where leaving the house to access care is not always simple. Additionally, reports have surfaced that accessing PCR tests are not as readily available in some communities. Given all of this, it seems imperative to not only keep access to health care facilities open, but to also avoid measures that would create additional barriers to accessing care.
I also think about those patients who have chronic conditions or elders in our community who must regularly access health care services to maintain their health. I remember feeling baffled when trying to coordinate care for an elderly family member who needed to visit an emergency department in July, only to be told that he required an appointment. Luckily, he was okay to wait until we secured an appointment, and then he received care – but emergencies are typically not planned. While the mandate states that anyone receiving emergency care would not be required to show vaccination status, who decides what is an emergency? Furthermore, if patients are now required to book appointments to access care, the general public will need assurance that measures have been put into place to deal with the inevitable upsurge in calls for appointment times – especially when complaints of not getting through to emergency services occurred even before Covid-19. The bottom line is that the hospital should be a space where anyone can access it at any time. No patient should ever be turned away from a hospital.
When planning to implement new Covid-19 restrictions there are several factors that must be considered and that should not be negotiable. First, hospitals, clinics and any health-related facilities should remain open to everyone. To avoid long lines and clustering of people, services should be open 24 hours a day, 7 days a week with more opportunities for people to access care. Shortened hours and limited days means greater numbers of people trying to access necessary resources which can create challenges for social distancing. Accessibility to any social service should also follow similar protocols, inclusive of services that are necessary for victims of violence. Anyone experiencing any form of violence should not be turned away because of vaccination status.
A coordinated and planned public health vaccination campaign is not a one-time initiative or one that has an end date. Rather, vaccine information should be consistent, accessible, geared to different audiences, and work across the board to develop relations with persons in positions of trust in specific communities to assist with the outreach. The same messaging may not work for all communities and the only way to target information is to speak with people to understand what their hesitation is. Furthermore, accessibility of vaccinations must also be considered when mandating goes into effect for the general public – particularly when vaccine supply has not always been consistent. Public health protocols must always consider travel and the economic costs communities consider when deciding whether they will comply with public health measures. Finally, when it comes to other measures that must accompany a vaccination campaign, there must be consistency in application and no double standards or exceptions to other measures – especially when it comes to curfews, indoor mask mandates and restrictions on large gatherings. This is the only way to build up trust in the general public.
Covid-19 will not disappear overnight. The last two years have taught us that we are in this for the long haul. This means that we have opportunities to re-think our approaches in tackling this disease, especially if our strategies have not brought about desired outcomes so far.
