Stephanie Ashby spent Saturday morning at the intersection of Pennsylvania Avenue and Henderson Street with her two children and a sign that read, “Not Anti-Vax, Anti Mandate.”

“I vaccinate my children. I vaccinate myself. What I do not stand for is being forced to it,” she said.  

The medical assistant, who’s also in nursing school, has worked for Texas Health Resources for almost six years. She wore her indigo scrubs to the protest in front of Texas Health Harris Methodist Hospital Fort Worth. The event attracted about 300 people, young and old, hospital employees and allies and their families. 

The gathering came just over a week after the faith-based, nonprofit hospital system announced all its employees must be fully vaccinated against the coronavirus by Sept. 10. Ashby, who’s 30 and a single parent, knows she will lose her job. She’s chosen not to get the COVID-19 vaccine — yet. She’s waiting for full FDA approval and more research about the vaccine’s long-term effects; she said she’ll revisit the decision in a year. It’s a strange experience, this mandate, an about-face from the gratitude she and her colleagues experienced when the pandemic began. 

“It was very liberating to be thanked and be recognized for your work, and that’s not even what it’s about. It’s just, it was a sense of pride,” she said. “Last year, we had free meals, you know, planes flying over just to thank us, and now it’s, we’re fighting for our jobs. I’m fighting for my family.”

People protesting Texas Health Resources’ COVID-19 vaccine mandate chant “freedom, not force” in front of Texas Health Harris Methodist Hospital Fort Worth on Saturday. (Alexis Allison | Fort Worth Report)

Texas Health Resources’ decision to mandate COVID-19 vaccines echoed those of Baylor Scott & White and Methodist Health System made earlier in the week. Days later, Cook Children’s and Children’s Health announced their own vaccine requirements. The mandates come amid a more than 800% increase in COVID-19 hospitalizations in Tarrant County since early June. 

“​​The policy is a crucial step to fighting the surging delta variant and will protect both patients and caregivers,” according to the Texas Health Resources’ press release announcing the decision. Texas Health Resources officials declined to elaborate on the statement.

Decisions like this one have garnered approval from across the medical community. In late July, national medical societies like the American Medical Association and American Nurses Association said they support vaccine mandates for health care workers.

But the mandates also tap into a larger dialogue about personal rights, bodily autonomy and what it means to protect your neighbor. And although the protesters represented a relatively small portion of employees — Texas Health Resources has more than 23,000 — about 30% still aren’t fully vaccinated, according to a statement by Chief Executive Officer Barclay Berdan. That’s about 7,000 people who work with and for patients across the system’s 28 hospital locations and who have their own families to support. 

“These are very thoughtful people,” said Larry Ashlock, a bioethicist who’s been on various hospital ethics committees throughout Tarrant County. He’s sympathetic to the health care workers who are hesitant about the vaccine. “They’re just trying to make decisions as best as they know how.”

But a hospital has an obligation to its patients, according to Stuart Pickell, a physician who chairs the Tarrant County Medical Society’s ethics consortium. 

“There’s always been an understanding that our role as physicians is to ensure the health and well-being of the patients we care for, and make them better to the extent that we’re able,” Pickell said. “Part of that is making sure that we aren’t contributing to them becoming sick.

And, he said, he thinks vaccines “work better than anything else” at doing so. 

Vaccine requirements for hospital employees are not new. Texas Health Resources already requires its employees to get the seasonal flu vaccine, as well as provide proof that they’ve received vaccines against measles, mumps and rubella; tetanus, diphtheria and pertussis; and chicken pox. But a key difference is that Texas Health Resources has allowed exemptions from the flu shot for “philosophical” reasons, but not the COVID-19 vaccine, according to Lauren Hughes, who has worked as a nurse with Texas Health Resources for eight years. She said she’s requested and received a philosophical exemption for the flu shot every year. 

Hughes organized Saturday morning’s protest, as well as an online petition requesting the hospital system to allow philosophical exemptions for the COVID-19 vaccine. By the time she closed the petition Friday, it had more than 2,000 signatures. 

Lauren Hughes, left, chats with another person at the protest against Texas Health Resources’ vaccine mandate on Saturday. Hughes is a nurse at Texas Health Resources and organized the protest. (Cristian ArguetaSoto | Fort Worth Report)

Another difference for Ashby, the medical assistant, is that the COVID-19 vaccine hasn’t yet been fully approved by the FDA. “We don’t know enough about this vaccine,” Ashby said. “We are the guinea pigs right now.” She said she’ll get the vaccine when she’s confident it won’t damage her body long term; full FDA approval will spur her confidence. 

By late February, the FDA had authorized three vaccines — the Pfizer, Moderna and Johnson & Johnson vaccines — for emergency use. The FDA intends to fully approve the Pfizer vaccine by Sept. 6, according to The New York Times. Still, emergency approval means the vaccines have been “rigorously tested,” according to the FDA’s explanation of how such its process works. For a vaccine to receive emergency approval, the FDA “must determine that the known and potential benefits outweigh the known and potential risks of the vaccine.”

Full approval requires even more rigor, said Bryn Esplin, a bioethicist and assistant professor at The University of North Texas Health Science Center. 

“They have to read about 10 times the amount of documents and evidence that’s submitted to get full clearance or FDA approval,” she said. “And so that’s on the horizon. The FDA has prioritized that review process, knowing how great the need is.”

Pickell, with the Tarrant County Medical Society, calls it a “paperwork problem.” 

“(The vaccines) aren’t fully authorized by the FDA, not because they’re dangerous, but because the paperwork involved in getting them to the point that they can have a biologic license is so onerous that it usually takes years,” he said. 

That full approval may give confidence to some people who worry that the vaccine is “experimental,” he said. Several people who signed Hughes’ online petition said there were too many unknowns about the vaccine for the hospital system to require it. 

“The legacy of distrust in the government and the government funding of human research trials, you might say ‘human experimentation,’ is very valid,” Esplin said. 

The fear of government-endorsed experimentation on people for medical research has a long history. In the 1930s, the U.S. Public Health Service began the Tuskegee study, where Black men took part in syphilis research without their informed consent. In exchange for their participation, they received basic needs support like free meals and medical exams. However, when penicillin became the widely recognized treatment for syphilis, the men didn’t receive it. 

Later, in the 1950s, children with mental disabilities at Willowbrook State School, a taxpayer-funded facility in New York, were intentionally exposed to hepatitis as part of a study on the infection. 

Stories like these erode public trust, Esplin said, and that distrust, even decades later, is “not easy to overcome.” 

“It’s interesting to think about those who say, ‘absolutely not — never,’ versus ‘not yet, and not me first,’” Esplin said. “‘Because I have historically been part of a community or population who has had to go first and be exploited in that way. And so let me just hang back for a little bit and see.’ And I think that that’s a very understandable position.”

Ashby is one of the people waiting and seeing. In the meantime, she’s wearing personal protective equipment, including an N95 mask, at work, where she said she sees COVID-19 patients every day. “I’m wearing my proper PPE to protect my patients and protect myself,” she said. “So what is the problem?” 

Proper PPE is “sufficient to prevent infection” among health care workers who work closely with COVID-19 patients, according to a September 2020 study in the Journal of Infection and Chemotherapy.

Furthermore, Ashby said, the vaccine isn’t fail-safe; fully vaccinated people can still contract COVID-19 and spread it to people around them. Still, a fully vaccinated person with COVID-19 may experience mild or no symptoms and will most likely be protected from hospitalization and death. For example, two doses of the Pfizer vaccine are 88% effective at preventing a symptomatic case of COVID-19 caused by the delta variant, according to a July study published in the New England Journal of Medicine. 

“We’re not going to deny our patients if they’re not vaccinated, so why should you deny my employment?” Ashby said. 

But health care workers, unlike patients, hold more sway over how people think and what people trust. 

“And while it is certainly a longstanding issue, in terms of bodily autonomy, and the right to refuse, health care workers — physicians, nurses — what they do matters,” Esplin said. “And so they have the public’s ear.”

For example, Americans trust medical doctors to look out for people’s best interest more than they trust elected officials, business leaders and the news media, according to a 2019 survey by the Pew Research Center. 

Ashlock said the need to set a good example is one of three arguments he’s seen for a hospital mandate like this one, along with health care providers’ “duty to care” and “do no harm.” And that makes sense, Esplin said, because people listen to and watch their health care providers. 

“You see patients being susceptible to misinformation, but the biggest studies tend to show that they trust their family physicians, to walk them through the risks, benefits, alternatives of treatment,” Esplin said. “And so if you can maintain trust on that sort of individual level with a health care professional whom you trust, that almost inoculates against the spread of misinformation or just helps unpack what is behind the hesitancy.”

Still, after a year of navigating the virus at work and home, health care personnel and other employees who work in the hospital are weary, according to Ashlock. A mandate feels heavy-handed after what they’ve been through, he said, and, at the end of the day, this is a “people” issue.

“They are walking through grief,” he said. “And perhaps they’re not wanting to go through that again.”

Alexis Allison is the health reporter at the Fort Worth Report. Her position is supported by a grant from Texas Health Resources. Contact her by email or via Twitter. At the Fort Worth Report, news decisions are made independently of our board members and financial supporters. Read more about our editorial independence policy here

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Alexis AllisonHealth Reporter

Alexis Allison covers health for the Fort Worth Report. When she can, she'll slip in an illustration or two. Allison is a former high school English teacher and hopes her journalism is likewise educational....

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