“It was like being slapped in the face. All my colleagues are in a state of shock as well.” Malika Belarbi, a nursing assistant at the Boulogne-Billancourt care home in the western suburbs of Paris and a member of the CGT Santé trade union, was still angry a day after President Emmanuel Macron's address to the French nation on Monday July 12th. During his televised speech the president announced that nursing staff will have to be vaccinated against Covid-19 by September 15th. Health minister Olivier Véran later made it clear that under new legislation staff who did not comply would face having their contracts – and pay – suspended for up to six weeks.
Malika says that the Covid health crisis has been “terrible for staff in medical-social establishments” and sees the government's decision as a “punishment”. She told Mediapart: “We work in very difficult circumstances and today, rather than supporting and helping us, we are suddenly told that if we don't get vaccinated between now and September 15th they won't pay us.”
The nursing assistant had been on the verge of getting vaccinated herself after initial doubts. But Monday's announcement has hardened her mood again. “I had taken the initiative to go and do it, but in a free and informed way. Not under pressure,” she said.
Malika is not the only sceptical voice raised over mandatory vaccines in her profession. According to the latest figures from the public health body Santé Publique France, dated July 8th, only 45% of staff working in old people's homes and long-term care facilities are fully vaccinated.
Meanwhile out of 287 staff who responded to a survey in care homes carried out by the CGT Santé trade union in the Hauts-de-Seine département or county neighbouring Paris, some 136 are still not vaccinated. Of these, 47.2% are resistant to doing so. In the comments attached to the report, many of those surveyed justify their refusal to get vaccinated through distrust of the government. “I'm not against vaccinations but I'm mistrustful!” said one of them.
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“It's worrying to see the vaccination rates in care homes so low,” said Gaétan Casanova, president of ISNI, a joint trade union body representing junior doctors in France. “Vaccination is necessary and we defend it 100%. And as healthcare professionals one should get vaccinated. We do it for ourselves and for collective protection,” he said.
“It's tragic that it's come to obligation,” said Sabrina Ali Benali, an emergency doctor who treats patients at their homes and also author of 'La Révolte d'une Interne' ('A Junior Doctor's Rebellion') published by J'ai Lu in 2020, and who does not herself question the need for vaccination. She considers that the debate goes beyond a simple for or against having a jab. “There's a global pandemic which has locked up everyone for a year, and yet there is so much mistrust that when we find a solution people reject it. How did we get to this point? To what extent must one have lied, corrupted and taken people for idiots that people still don't believe in it?” she wondered.
Dr Jérôme Marty, a self-employed GP and president of the organisation UFML (Union Française pour une Médecine Libre), which represents doctors from all sectors of medicine, thinks that the government has got its strategy wrong. In March 2021 the UFML advised the Ministry of Health to “organise meetings in all the medical-social and medical services, with nursing directors, management, nurses, non-nursing staff … to dispel doubts, fears and questions. So that more people would be vaccinated,” recalled Jérôme Marty. “That wasn't what the Ministry chose to do, and six months later we find ourselves with the need to move to mandatory vaccination because we've lost too much time.”
ISNI president Gaétan Casanova also points to the “chaotic communications” over vaccinations. “When you say: there needs to be widespread vaccination of nurses with AstraZeneca, then you have a young person who gets a blood clot – that can happen, there are undesirable side effects as with all medication – and the government then announces a suspension of the vaccine, then resumes it, then suspends it again … it provokes a lot of anxiety. You got the impression that even the government wasn't sure about what it was saying in relation to that.”
This confusion might partly explain the low vaccination uptake among healthcare staff. “I find it hard to understand the wish of doctors and nurses not to get vaccinated, but I understand it more easily when it comes from professions which have have less health and scientific training,” said Jérôme Marty, drawing a distinction between medical staff and carers.
“Among junior doctors mandatory vaccination is virtually a non-issue,” said Gaétan Casanova from ISNI. When the representative body surveyed 3,500 junior doctors it found that 95% of them were already vaccinated and 82% back the measures that President Macron has now announced.
Meanwhile, for high-risk patients who have watched with growing fear as Covid restrictions have been relaxed in recent weeks , the decision to have mandatory vaccination for healthcare staff comes as a relief. “Patients on dialysis or who have had transplants have a mortality rate 20% higher than residents in a care home!” said Yvanie Caillé, executive director at the health data body the Institut National des Données de Santé, founder of the kidney patient association Renaloo, and a member of the vaccination advisory body the Conseil d’Orientation de la Stratégie Vaccinale. “Without massive vaccination in healthcare locations conversations were becoming difficult with the nurses, and dialogue sometimes impossible and violent; a decision had to be made and it's true that the threat from the Delta variant has hurried things along.”
From wave to wave we locked down, tightened up, banned; that preserves the hospitals, but it doesn't resolve the crisis in the long term.
André Grimaldi, a diabetes specialist in Paris who runs a discussion forum involving many doctors, is also pleased at the measure, though he said he found it hard to understand why colleagues saw the introduction of mandatory vaccines as them being “stigmatised” rather than “privileged”. However, he is under no illusions about the real nature of President Macron's strategy. “The president appeared small and weak from the start of the crisis, here he's regaining control by serving his own political purposes,” he said. “On the one hand he is relying on the collective values of vaccination, of public service and of the general interest, and on the other he is relaunching his liberal reforms. In short, he's using vaccinations - which are accepted by the majority of the population - to help get through an economic policy that has minority support ...”
Academics and legal experts who have worried since the start of the crisis about the weakening of the rule of law in France fear that this new policy on vaccinations will diminish still further the credibility afforded to public declarations, which are crucial to public health policy. “Once again, there's been no real discussion or deep debate about these new measures, despite their restrictive nature in relation to freedoms,” said Stéphanie Renard, a lecturer in public law at South Brittany university in the west of the country. “Parliament wasn't even consulted in advance, even though these measures can't be implemented without the intervention of the legislature.”
As well as announcing mandatory vaccinations for healthcare workers on Monday, President Macron also hinted that jabs could be made obligatory for everyone from the age of 12 if there is not a significant increase in vaccination numbers by the end of the summer. The independent French health authority, the Haute Autorité de Santé, has been backing such a move for several weeks. The move announced on Monday to bring in health passes or 'Covid passports' that people will need for much of everyday life - to go to restaurants or travel on trains, for example - is also seen as an attempt to bring in vaccination for all under another name. Many people will simply not be able to have a normal life unless they are vaccinated. Protests against these moves were held on Bastille Day, July 14th, in Paris.
If mandatory vaccinations for all are introduced it would not be the first time. The first such obligation in France dates back to 1902 and involved smallpox, which has since been eradicated. During the course of the 20th century it was extended to eight vaccines for children, and by 2018 the number of mandatory jabs was eleven; though these measures have not always been introduced without controversy. In French Guiana, meanwhile, there has long been an obligation to have a yellow fever vaccine.
And unlike the plans for a health pass or 'Covid passport' - permitting people to enter cafés or travel on trains – mandatory vaccination already has a basis in law. Under Article L1111-4 of the Public Health Code “no medical act or treatment can be performed without the free and clear consent of the person”. Yet as Diane Roman, professor of public law at the Sorbonne law school in Paris pointed out in La Croix newspaper, the French Constitution counterbalances this with the principle of “health protection”, as long as the mandatory vaccination in question is deemed to be “proportionate”. It was on this basis, and in two different cases, that in 2015 France's Constitutional Council and then in 2021 the European Court of Human Rights ruled against parents who had refused obligatory vaccines for their children.
However, a new law will still need to be passed for the obligatory Covid vaccines. Law lecturer Stéphanie Renard points out that France is no longer under the legal regime of a health emergency but is in the “strange parenthesis of 'exiting from the health crisis'”, as the latest legislation dating from May 31st puts it. “As an obligation to have a vaccine relates to a violation of one's physical integrity, only the legislature can allow it and define the forms of punishment,” she said. “So Parliament will have to intervene to define this obligation and determine how it is applied and decide on the punishment if it is ignored.”
Imposing a vaccine on everyone would involve massive monitoring of the population. In 2018 the French Parliament removed the prison sentence and the fines that had originally been aimed at parents who did not respect the obligation to get their children vaccinated. But children cannot be taught in crèches or state or private schools if they do not have a document to show they have received their jabs. Should punishments of this type be brought in for vaccines against Covid-19? And can one enforce such an obligation without being sure that the whole population has equal access to a vaccine?
A genuine public health policy is something which has been lacking in France since the start of the crisis.
Another key aspect of the government's plans to bring in mandatory Covid jabs for healthcare workers is what it says about the success - or otherwise - of France's public health policies during the epidemic. On Monday evening President Macron congratulated himself over his government's handling of the crisis. But this new move towards obligation, which doctors have called for in order to head off a possible fourth wave of the virus, can also be seen as a repudiation of the public health policy that the government has adopted over the last year and a half - including the crucial policy on vaccines.
“Having mandatory vaccines 'disguised' as a health pass is not the only means of reaching those people who have not yet got vaccinated,” said the public service rights collective Nos Services Publics. “However, an alternative route involves building a genuine public health policy - something which has been lacking in France since the start of the crisis - which would enable people to be convinced.”
In that sense, says public health expert Linda Cambon, the state has “failed somewhat in everything”. First of all, says the academic from Bordeaux University, there was a failure to treat the epidemic as what it really was from the start, namely a “syndemic”. This means there were a number of factors that worsened the spread and seriousness of the contagious illness, such as social conditions, comorbidities, age and so on. “From wave to wave we locked down, tightened up, banned; that preserves the hospitals, but it doesn't resolve the crisis in the long term,” she said.
The second failure was in the communications strategy, which was based largely on individual responsibility and fear, ranging from the word “war” that was bandied about in March 2020 to the division now in July 2021 between good and bad citizens. “It's a recurring issue in public health,” said Linda Cambon. “You show terrible black lungs to smokers and people torn apart on the road to car drivers, and that works through fear in the short term, but over the long term people adapt and bypass messages that seem too stressful to them.”
This communications strategy can have two damaging effects. Either it causes “enormous anxiety”, with the result that people shut themselves away or overprotect themselves at home without good reason, or they become mistrustful and even reject the messages and the messenger – in this case the government. In Bordeaux, where Linda Cambon's team has been involved with the push to get hospital nurses vaccinated, she says “dialogue has been able to persuade 100% of the medical staff, by taking the time for discussion, at a local level, about the risks, the benefits for oneself, for one's family, society”. This takes time and resources that the government does not have – or no longer has – faced with the Delta variant.
Several figures in public health continue to think that the infectious disease experts, intensive care specialists and modellers who have mostly made up the Scientific Council government advisory body since the start of the epidemic are not the best-placed people to persuade the public about preventative measures. “We also know that the executive has used more informal teams of consultants specialising in nudge technique, which is based on marketing principles, and consists of silent compulsion that gives people the impression they have a choice,” said Linda Cambon. She sees the new restrictions of the health pass – introduced against the backdrop of a threat of a fourth lockdown - as the culmination of this approach. “It's not a vision of public health that we share,” she said.
However, the government could well respond that this form of subliminal threat works. For within a few hours of Emmanuel Macron's announcement on Monday evening millions of people had rushed to online reservation sites to book a vaccination, worried at the prospect of a summer in which they are restricted from doing what they want, or perhaps even fearful of an early autumn in which they will be forced to get a jab.
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English version by Michael Streeter