Masks are off. Theaters and indoor dining are back. Life seems to be returning to normal. And yet the highly transmissible and maybe more deadly Delta variant is spreading quickly, accounting for half of new Covid-19 cases in the U.S. and causing surges in nearly half of all states. New studies demonstrate the effectiveness of vaccines against this new variant’s immune evasiveness properties, which pose a serious threat to partially vaccinated or unvaccinated individuals.
Education and factual information haven’t gotten us even halfway to a fully vaccinated population. States have tried $1 million lotteries and other incentives. Yet just 1% of the population is becoming vaccinated every week. We need to move on to something else: employer mandates.
Universities are requiring students to be vaccinated and many, including our own University of Pennsylvania, are also mandating that staff and faculty get the vaccine. United and Delta Air Lines, which fly hundreds of passengers in close quarters, are requiring vaccines for all new employees. Even employees of the Broadway hit “Hamilton” will be required to get vaccinated to keep cast and audience members safe.
One industry that has been strangely silent about mandates is health care, including hospitals, home health agencies, long-term care facilities, and others. Why aren’t all 17 million health care workers at hospitals, nursing homes, skilled nursing facilities, home health care agencies, and outpatient care sites such as federally qualified health clinics, pharmacies, physician offices, physical therapy offices, and the like required to get vaccinated against Covid-19?
Since the start of June, there continue to be roughly 150 deaths per week among nursing home residents due to Covid-19. Nearly 80% of nursing home residents have already been vaccinated, well above the 70% or so threshold most experts cite for achieving herd immunity. The problem appears to be low vaccination rates among staff.
Nationwide, only 55% of these staffers have received the Covid-19 vaccine, and great variability exists from one nursing home to the next. In New York state, 85% of nursing home residents have been vaccinated, while in many facilities less than 40% of staff have been vaccinated, including one in Oneida County where only 16% of staff were vaccinated.
While every Covid-19 death is a tragedy, those in nursing homes are particularly so because most of them are avoidable. Many have been traced to unvaccinated workers who then infect other workers and vulnerable residents who cannot mount strong immune reactions to the vaccine.
The low vaccination rate among health care workers is not limited to long-term care facilities. A survey of nine hospital networks found rates of fully vaccinated workers were as low as 53%. Even worse, as we rely more and more on out-of-hospital care, it turns out only 26% of home-health workers had been vaccinated as of March. A survey released in April found that fully 30% of health care workers are “vaccine hesitant” with 18% of frontline workers outright opposed to vaccination.
It’s one thing for a retail worker not to get vaccinated. It’s unethical and appalling for a health care worker.
No vulnerable, immunocompromised patient — older adults, cancer and transplant patients, individuals with HIV/AIDS, and others — trying to beat their disease should have to worry that the people caring for them may be asymptomatic carriers of Covid-19.
According to the American Association of Medical Colleges, just three weeks ago only a half-dozen health systems, including the University of Pennsylvania Health System, where we work, as well as Methodist Hospital, NewYork-Presbyterian, Johns Hopkins Medicine, and nearly all hospitals in Washington, D.C., had mandated all staff be vaccinated against Covid-19. While more health systems have started to introduce vaccine requirements in recent weeks, it may take months for a significant number of health care organizations to follow suit, during which time new variants and challenges could emerge.
Meanwhile, mandates have been highly effective. Nearly 250 long-term care facilities operated by three companies introduced mandates and achieved approximately 95% vaccination rates among staff as a result.
Mandating vaccination isn’t just the right thing to do, it’s also the ethical thing to do. All health care workers pledge that their highest duty is to promote the best interests of their patients. In the words of the Hippocratic oath, physicians pledge that, “Into whatever homes I go, I will enter them for the benefit of the sick …” (There were no hospitals at the time of Hippocrates, only home care.) Nurses pledge to “devote myself to the welfare of those committed to my care.” And on it goes for all health care workers, from phlebotomists to pharmacists: They all pledge to use their skills to “assure optimal outcomes for my patients.”
A vaccine mandate simply puts into effect health care workers’ promise to patients and the community.
The health care industry’s commitment to these words is facing a test on which patients’ lives depend. Health care organizations and leaders, from the American Medical Association to the American College of Physicians, American Nurses Association, American Hospital Association, and the Association of American Medical Colleges to CEOs of leading institutions such as Stanford University, the Mayo Clinic, Massachusetts General Hospital, and points in between should unequivocally proclaim that every health care worker in the country has a duty to be vaccinated against Covid-19 and that health care institutions and other employers should mandate vaccination.
Why has it taken so long for health care to lead on Covid-19 vaccinations? Some say the industry is waiting for the vaccine to be formally and fully approved by the FDA. Others offer up worries about the legality of mandates; that workers will quit, making it hard to fill the jobs; or weighing into a public controversy.
None of these are valid excuses. Leadership requires taking the moral road even when it isn’t popular. And medical ethics — backed by recent regulatory and court decisions — supports the mandate decision as the best course for the nation’s health.
The vaccines currently available in the U.S. are as safe and effective as any vaccine available — and are a whole lot safer than getting Covid-19. The FDA will likely grant full approval for the Pfizer and Moderna vaccines within a month or two. Guidance from the U.S. Equal Employment Opportunity Commission had made it clear that employers have the legal authority to mandate a vaccine and they can do so even if the vaccine has only an emergency use authorization. Last month, a federal judge in Texas dismissed a case by 117 staffers at Houston Methodist over the hospital system’s vaccine mandate, effectively confirming such mandates as legal. Fully 25,000 employees complied with the mandate.
The vast majority of workers are unlikely to quit in response to a mandate. Few did at Houston Methodist. And Atria Senior Living was one of the first senior care companies to mandate vaccines when it announced in January that all 10,000 employees must be fully vaccinated by May 1. The company has reported that due to its efforts combining the mandate with education and support, employees embraced the vaccine, and the company reached a 98% vaccination rate. Other senior living companies — within an industry with chronic staffing shortages — have followed in recent months with similarly successful results.
Throughout the Covid-19 pandemic, health care workers have gone beyond their professional oaths, at times dealing with shortages of personal protective equipment and facing personal risk to care for patients. Now, a year later, unvaccinated health care workers are putting patients at risk and prolonging the very crisis they have been on the frontlines fighting.
The time is overdue for leaders of hospital systems and the physician, nurse, and long-term care worker communities to step up and fulfill their duties to put patients and community health first.
Ezekiel J. Emanuel is a physician, vice provost for global initiatives, and co-director of the Healthcare Transformation Institute at the University of Pennsylvania. Patricia Hong and Matthew Guido are researchers in the Department of Medical Ethics and Health Policy at the Perelman School of Medicine at the University of Pennsylvania.
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