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(CNN) -
Earlier this month, Austria took a previously unthinkable step for a Western democracy: it announced that covid-19 vaccines would be mandatory for its entire population.
Until then, governments around the world had rejected the idea of a universal coronavirus vaccination mandate, opting instead for incentives and other "nudges" to motivate people to get vaccinated.
Even in authoritarian states, like China, it is not a mandatory policy.
Austria's extraordinary move came just days after it introduced a lockdown for the unvaccinated, a restriction that went further than other European nations in singling out people who have been causing a worrisome spike in hospitalizations.
The series of decisions that brought Austria to this point reflects the desperate position governments find themselves in as they seek to protect public health systems and tentative economic recoveries as cases skyrocket across Europe.
The continent is once again ground zero for the global pandemic, despite the wide availability of vaccines.
Austrians take to the streets against new confinement by covid-19 2:20
It is that irony that has drawn the ire of European leaders, who are increasingly frustrated by vaccine skeptics and other sectors of the population who still resist COVID-19 vaccination programs.
Austria's tough new measures were unveiled ahead of the omicron variant discovery announcement late last week, sparking fears that the winter wave of covid-19 could be more brutal than previously thought. .
News of the variant could push more countries to tighten their approach, moving from voluntary to mandatory measures in a last-ditch effort to get more vaccinations.
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"We have enough vaccines. Science gave us the possibility, the ticket out of this vicious cycle of virus waves and lockdown discussions. And there just aren't enough people who are using this possibility and taking this ticket out, and that is why we are still stuck in this situation, "Austrian Chancellor Alexander Schallenberg told CNN last week, explaining his decision to require covid-19 vaccines by February 1.
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Those who do not comply with the rule will face an administrative fine, but it is unclear how the policy will be enforced.
Almost one in three people in Austria remains unvaccinated.
"It is a drastic measure. I would have preferred to go the other way. But a year after having the vaccine, doing national campaigns, the media explaining again and again what this is about, that we have such a degree high of insecurity, of people who believe in fake news ... we need to take this drastic step, "added Schallenberg.
The generally crowded Christmas market near the cathedral in Vienna closed last Monday.
Drastic measures
Other countries are beginning to consider similarly drastic measures to persuade more people to get vaccinated, despite criticism that low vaccination rates make them unrealistic and would deprive millions of earning a living.
On Sunday, days after scientists in his country first reported the existence of the omicron variant, South African President Cyril Ramaphosa announced that authorities were investigating whether to require covid-19 vaccines, and vaccines. reinforcement, for workers and for the entrance to some public spaces.
Kenya was one of the first African nations to introduce restrictions on the unvaccinated last week.
Scientists are still reviewing the data to assess how effective existing vaccines are against the new variant, but Moderna's CEO warned in an interview with The Financial Times that he believes it will amount to "a material drop."
Dr. Anthony Fauci, chief medical adviser to President Joe Biden, has said that he believes existing vaccines should provide a degree of protection against severe cases.
"Vaccination will be the solution to this, be it the delta variant or the omicron variant," Fauci told CNN's Jake Tapper.
The question of whether or not to pull the trigger on mandates, and how to weigh the risk to civil liberties against a serious threat to overburdened healthcare systems, has caused much nervousness around the world, especially in Europe, a proud bastion. of liberal democracy.
But just as lockdowns have become part of pandemic life, the rapidly emerging view in Europe is that vaccination mandates are not only plausible, they could pay off.
The rules in France, Italy, and now Austria provide a window into what to expect.
Austria has seen an increase in vaccination since the beginning of November, when the government began to signal stricter measures for workers.
In four weeks, vaccination coverage increased by about 4 percentage points, more than other members of the Western European Union during the same time, according to the Our World in Data project at the University of Oxford.
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After the initial lockdown of the unvaccinated on Nov. 14, half a million more people received their first dose, according to the chancellor.
That upward trajectory has continued, although the vast majority of vaccines are booster vaccines, said Peter Klimek, associate professor at the Medical University of Vienna and adviser to the Austrian Ministry of Health.
"From a modeling perspective, it is clear that if you increase the absorption of the vaccine, it will not be enough on its own to stop the circulation of the virus, but it is a big step in stopping the collapse of the healthcare system," Klimek said.
"Will a mandate help? Yes, if we find ways to make it work."
Since Austria's vaccination mandate has sent tens of thousands of people to the streets in protests, many more have gone to vaccination centers.
"I gave in to government blackmail. I wanted to wait, but the government had other plans for me," Jaruslav, who gave only his first name, told CNN while receiving his first dose at Austria's largest vaccine center in Vienna. .
"Control the border. Not your own people," reads a banner during a demonstration against covid-19 restrictions in Austria.
While some people will not change their minds, others, like Jaruslav, will, albeit reluctantly. For the price of some protests, some European politicians are beginning to conclude that it is worth pushing to force a part of the population that would otherwise have been difficult to win over.
Explaining Austria's decision, Schallenberg noted the successes of Italy, its neighbor to the south, and France, which have introduced vaccination mandates in everything but name, requiring health passes such as proof of vaccination, a negative test, or recent recovery from the infection to attend meetings, travel or go to work, along with public health measures, such as the use of masks. Both countries have also made vaccination mandatory for healthcare workers. They are two of the five countries that make it in Europe, according to the European Center for Disease Prevention and Control.
France was the first to set the trend toward mandates in Europe, after the rollout of vaccination was halted.
"France is definitely the model for this work," said Thomas Hale, who has been compiling countries' policy responses as part of the Government Response Tracker to Covid-19, run by the Blavatnik School of Government at Oxford.
Do the mandates work?
Hale and his colleagues are in the process of adding data on covid vaccination mandates to their tracker in order to answer the big question: do they work?
Of the more than 180 countries tracked by the Blavatnik School of Government, Hale said some stood out for having effective mandates: France, Israel, China and Brazil.
Earlier this year, Israel became a model for defeating the covid with the use of a vaccine passport, the so-called "Green Pass."
But it experienced a devastating rise in infections driven by the fast-spreading delta variant during the summer after it removed the pass system and removed other restrictions.
In China, where the pandemic began, the government has achieved a high level of vaccination through a series of controversial carrot-and-stick incentives.
These require vaccinations for students and workers, while penalties are applied for those who do not receive a vaccine, through credit ratings.
Since several Brazilian cities, including Rio de Janeiro, began introducing divisive vaccine passports this fall, Brazil, once devastated by the virus, has now surpassed the United Kingdom as one of the most vaccinated countries in the world.
"There is an upbeat story to tell that, for the vast majority of people, this is not really that controversial. There is a lot of focus on those who resist, and rightly so. But it is quite a move in the right direction," Hale said.
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The case of France
Nowhere has it been more apparent than in France, where President Emmanuel Macron announced the health pass, or "health pass," on July 12, prompting a dramatic increase in vaccination appointments.
Doctolib, the leading platform for booking vaccination appointments in the country, saw 1 million appointments made in 24 hours.
Thanks in part to its rising vaccination rate, coupled with a massive spike in covid-related testing and the reintroduction of mask mandates in regions hardest hit by the delta variant, mainland France largely managed to bypass the fourth wave that swept Europe during the summer.
Around 70% in France are now fully vaccinated.
Vittoria Colliza, a Paris-based epidemiologist at Inserm, the French public health research center, told CNN that the introduction of the pass "was the key to getting out of a stalemate, in which we had reached a saturation point. ". And it showed that it was possible to incentivize people who were previously reluctant to get vaccinated. But now, as European countries with high vaccination rates struggle to contain another spike in cases, Colliza said it was clear that additional incentives would be needed to escape the worst as immunity wanes.
A June study in Israel revealed that while vaccines still offer strong protection against severe COVID-19, their effectiveness in fighting the virus diminishes over time, accelerating the need for a third booster dose.
Since then, he has restored his green pass and demands a third dose for his renewal.
Macron recently said that a booster dose for those over 65 would be necessary to revalidate their health pass starting in mid-December, in an effort to ensure absorption and avoid the fifth wave.
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Vaccination in Italy
Italy followed the path of France in July, with Prime Minister Mario Draghi announcing a similar health pass, demanding it as proof of immunity to access a variety of venues and services. Although Italy did not experience the same initial spike in vaccines as France, politics has helped slowly turn the dial. And, last month, Italy went further than France to introduce what was until recently the toughest measure in Europe: a "Green Pass" that requires all workers in the nation, both public and private, to be vaccinated, prove that they have recovered or test negative for covid to receive their payroll.
Since the measure was announced in mid-September, Italy's vaccination coverage has increased by around 5 percentage points.
Although not a huge increase, experts argue that at this stage of the pandemic, every percentage point helps.
Dr. Roberto Burioni, a prominent Italian virologist at the University of San Raffaele in Milan, said that the strict measures of the expanded health pass have not only allowed the country to fully vaccinate around 73% of the population, but also avoid painful restrictions, such as the lockdown now in place in Austria.
Burioni also said that the pass, which is necessary to access the nightlife, had motivated young people in Italy to receive the doses.
"What in my opinion was the most notable effect is that we experienced a very, very high vaccination rate in the 20 to 30-year age group," Burioni said, estimating around 84%. "These young people are very important in spreading the virus. Because, you know, they have a very intense social life. They are one of the reasons why Italy is in a better position than other countries."
But he said that even with tough mandates and his efforts to combat anti-vaccine misinformation as part of Italy's covid strategy, there is still a small and noisy minority of the population that is against vaccines, and apparently nothing will change. Your opinion.
That group, while small, still poses a big problem for Italy to reach its ultimate goal of vaccinating 90% of the eligible population, Burioni added.
"I can't believe someone is refusing to do this after 150,000 deaths in Italy; everyone here has a relative, a friend who died of covid. I meet people in the intensive care unit with covid who still say they would not receive the They have no regrets, they say 'Oh no, please don't vaccinate me.'
They check the green pass of a man in the port of Genoa.
Evaluation of mandatory vaccinations
While the politicization of covid vaccines, particularly by populist groups in Europe, has made many governments reluctant to enforce mandates on their populations, the risk that severe closures cancel another opportunity in a recovery season The holiday season has led many to reevaluate.
As cases increase in Germany, the country's health minister warned that by the end of winter, "almost everyone in Germany will probably be vaccinated, recovered or dead." Since Wednesday, a new law requires all workers to provide proof of vaccination, recovery or a negative test; Those who do not comply will not be able to enter your office and could be left without pay. And Olaf Scholz, Germany's incoming chancellor, said the new coalition would consider vaccinations mandatory because "vaccination is the way out of this pandemic."
In Greece, where infections are on the rise, Prime Minister Kyriakos Mitsotakis said on Tuesday that covid-19 vaccinations would be mandatory for all citizens over the age of 60.
The Greek government had recently banned unvaccinated adult citizens from entering cinemas, theaters, museums or gymnasiums, with or without proof.
Access to public services, banks and shops without a negative test was already restricted for the unvaccinated.
The Czech Republic, which is experiencing its highest number of cases from the pandemic, is also tightening requirements along similar lines.
Increasing restrictions on the unvaccinated is part of a broader movement toward vaccination mandates globally, says Thomas Hale.
"Austria is a very dramatic example. But it is part of a larger trend."
United States, the counterexample
There are counterexamples in which the effectiveness of the mandates has been less clear.
In the United States, immunization rules for federal workers, members of the military, and people who work in healthcare settings have contributed in some way to increasing acceptance among those groups, but it is difficult to say whether they have had a significant impact on the population. overall, Hale says.
The Biden administration has also tried to require that private companies employing more than 100 people be fully vaccinated or undergo regular testing, but the measure is tied in court.
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But as countries aim to use lockdowns more judiciously, or avoid them altogether, Hale believes we will continue to see more leaders move toward mandates. UK Prime Minister Boris Johnson said in mid-November that the definition of "fully vaccinated" would have to change at some point to account for booster shots. And, on Monday, the UK announced that it would offer booster shots to all adults, narrowing the gap between the second and third doses from six months to three, in an effort to curb the spread of omicron.
"I think [the mandates] work. I think they especially motivate people who are not averse to vaccines, but who are a little vague about vaccines, a little indecisive. And in some countries, that's a big part of the population, "Hale said, pointing back to France.
"But if you are up against people who are really against vaccination, then it is not so clear to me that those measures will remove that barrier."
Eliza Mackintosh wrote and reported from London. Jo Shelley and Salma Abdelaziz in Vienna, Nina Avramova, Stephanie Halasz, Sarah Dean and Chris Liakos in London, and Inke Kappeler in Berlin contributed to this report.
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