Austria’s mandatory Covid vaccine plan ignores the lessons of history

By By Dr Agnes Arnold-Forster and Dr Caitjan Gainty. Dr Agnes Arnold-Forster (London School of Hygiene and Tropical Medicine) and Dr Caitjan Gainty (King’s College London) are health historians.

"Austria is to become the first European country to make vaccinations against Covid-19 mandatory. A general vaccine mandate will come into effect on 1 February 2022, with exemptions permitted on medical grounds.

The country has the lowest vaccination rate in western Europe, with just 66 per cent of its population fully vaccinated. The Government has tried to encourage uptake with mandatory vaccine passports at restaurants and bars, and by announcing a lockdown specifically for those unvaccinated.

The proposal has been met with substantial opposition, partly fuelled by the far-right Freedom Party. But over the weekend, 40,000 people protested in the streets of Austria, including many unaffiliated to the right-wing extremists. Opposition has been framed in terms of medical ethics, bodily autonomy, and resistance to an overly-interventionist state power.

There are good arguments in favour of compulsory vaccinations, and this is a politically risky decision that the Austrian government is unlikely to have taken lightly. There is historical precedent for such measures, and past epidemiological data suggests that they can work.

In the United States, between 1919 and 1928, the four states where mandatory vaccination was prohibited had 115.2 cases of smallpox per 10,000 people. In contrast, the 10 states with vaccine mandates had just 6.6 cases per 10,000 people.

Yet, history also reveals significant problems with compulsory vaccinations. Indeed, there is plenty of evidence to suggest that mandates increase hesitancy, rather than reduce it. In 1853, the English government made smallpox vaccination compulsory. As in Austria today, this new policy was met with widespread protest. It kick-started a concerted and coordinated anti-vaccination movement, that spread its tentacles across the globe.

There were riots in several industrial English towns, like Leicester, and new “anti-vaccination leagues” were established. These leagues published pamphlets and held rallies, and communicated with kindred spirits abroad. The Anti-Vaccination Society of America was founded in 1879, following a visit by leading British anti-vaccinationist William Tebb.

Compulsory vaccination was understood as a tool of an increasingly interventionist government, and many of the protesters were working class people, who had been living under the brutalising regime of workhouses and the Poor Law. In 1898, the British Parliament passed an act to allow parents to opt out of the compulsory system, and the legislation was expanded in 1907. Since then, and in contrast to many other western nations, Britain has avoided vaccine mandates entirely.

Indeed, though you can make a convincing case that Britain was the birthplace of the nineteenth century global anti-vaccination movement, in the twentieth century, vaccines became unusually popular in the UK.

This change was neither linear nor straightforward, but concerted campaigns on behalf of an increasingly respected, well-resourced, and trusted welfare state and scientific community transformed controversial routine vaccinations into commonplace medical interventions. When the NHS was founded in 1948, two vaccines were routinely given to children. By 2018, that number had risen to 17. Polio has been a particular success story. The first effective vaccine was developed in 1952, and today, around 94 per cent of British children are vaccinated against the disease before their first birthday. 

So while there has been a lot of coverage of vaccine hesitancy here in Britain during the pandemic, that does not accurately reflect the uptake of either the Covid-19 vaccines, or of jabs more generally.

In a 2016 survey, 89.6 per cent of British respondents agreed or strongly agreed that vaccinations were important; 84 per cent concurred that they were safe; and 86.7 per cent agreed that vaccination was effective. Almost 90 per cent of Britons over the age of 12 have received at least one dose of the Covid-19 vaccine – a figure achieved without vaccine mandates or widespread use of passports.

At this stage of the pandemic, Austria – along with other nations – has already vaccinated those who would do so voluntarily. We know from both historical data and more recent experience that at least some of those who remain are likely to have deep-seated suspicions of both public health systems and the state, often borne of experiences of marginalisation and memories of abuse and exploitation. Vaccine mandates will do nothing to ameliorate these concerns; indeed, they are more likely to exacerbate them.

Ultimately, history cannot predict whether Austria’s new vaccine will succeed in achieving a higher national vaccination rate. But it does suggest that such mandates must be approached with great caution. Government compulsion can but does not always achieve increased vaccine uptake, and when it does it can come at the expense of trust and social inclusion. There are no hard and fast rules here.

Instead, what history does make clear is that the success or failure of vaccine mandates are deeply contingent and dependent on national context and the historical moments in which they take place.

Britain has arguably had greater success with gentle persuasion, and a much-loved healthcare system, than compulsion and coercion. It remains to be seen whether vaccine mandates will harm or help Austria’s own public health aims."