As cases of the Delta coronavirus variant have risen and vaccination rates slowed, several US businesses and institutions have announced they will now require vaccinations from employees.
Major companies like Walmart and Disney said this week all employees must be vaccinated, while Joe Biden said all federal employees must be vaccinated or face masking, testing and distancing requirements.
Schools, universities, hospitals, financial services, tech companies, retailers, entertainment industries and local governments have announced similar policies.
The efforts are supported by an opinion from the US Department of Justice, which says employers can require vaccines under emergency-use authorization.
“Overall, it’s legal to require vaccinations in the midst of an active, dangerous epidemic,” said Ross Silverman, professor of public health and law at the Indiana University.
In France last week, President Emmanuel Macron said entrance to many public places would require a “health pass” showing proof of vaccination, prior infection or a negative test.
The US government won’t mandate vaccines but states, cities and businesses can.
The US has a long history of requiring vaccines. In winter 1777, George Washington required smallpox inoculations for all soldiers fighting the British. In 1809, Massachusetts passed a law requiring proof of inoculation against smallpox.
Dr Ruth Faden, founder of the Johns Hopkins Berman Institute of Bioethics, said: “If we look at the history of the ability of human beings to control infectious diseases, it’s hard to imagine how we would have been able to accomplish what we’ve accomplished in the absence of mandates of one sort or the other.”
With measles and diphtheria, for example, “it was not merely the advent of the vaccine but the requirement that the vaccine be received … that made the difference.”
By 1980, schools in all US states had laws requiring vaccinations for students. Some places offered religious or philosophical exemptions. Such rules were put to the test in a measles epidemic in Philadelphia in 1991, when 1,400 cases and nine deaths were mainly clustered in two churches whose members requested exemption from vaccination.
“Philadelphia was a feared destination,” said Dr Paul Offit, director of the Vaccine Education Center and an infectious disease physician at Children’s Hospital of Philadelphia. “Schools canceled trips to the city. People were afraid to come.”
The measles vaccine became compulsory. “Everyone in those schools had to be vaccinated, even though the parents didn’t want them to be,” Offit said.
One pastor asked the American Civil Liberties Union to represent the churches but it declined, Offit recalled, on the grounds that “while you are at liberty to martyr yourself to your religion, you are not at liberty to martyr your child”.
In 2019, New York mayor Bill de Blasio mandated vaccines following a measles outbreak in some religious communities.
In the grip of the Covid pandemic, mandates seem a logical next step, experts say. Vaccines are safe and effective, widely available and more needed than ever as the Delta variant spreads.
“That’s where the rubber is about to meet the road,” Offit said, “because we cannot allow this to happen.”
Allowing the virus to circulate will put those not eligible for vaccination, like children, and those who not protected well, like the immune-suppressed, at risk. Unchecked spread means more variants will emerge, probably making vaccines less effective.
“We’ve done all of these things to try to encourage and make it as easy as possible and reduce as many barriers as possible to getting vaccinated,” Silverman said. “Yet we still have this gap in our protection that is causing significant risk to a large part of the population.”
The risk isn’t just severe illness and death, Silverman added, but also long Covid, a debilitating condition.
Vaccines won’t be compulsory. People may request medical or religious exemptions. It will be up to employers to approve or deny requests.
“It becomes a question of whether or not granting that exemption would create a severe risk in the work environment,” Silverman said.
In hospitals and long-term care facilities, for instance, unvaccinated staff represent an enormous risk to their patients and residents and employers may deny exemptions in these circumstances.
“Workers may choose not to be vaccinated, but that may mean they’re no longer able to work in the same job.”
Unvaccinated retail or restaurant workers, on the other hand, might be able to use masks and testing.
“There’s no one way, there’s no gold standard, for how these things are being managed,” Silverman said. “What they’re going to do for Broadway may look very different from what the NFL is going to accept.”
Some states have passed laws limiting vaccine mandates. But companies may mandate vaccines because it’s the safest way to protect employees and customers and keep their business going.
There’s also an ethical imperative to mandate vaccines, Faden said.
“There’s an awful lot of good, an awful lot of human welfare that could be promoted here, a tremendous burden of disease and death could be prevented.
“It’s not only our physical health that we’re concerned about. All of these things that make our lives go well are being threatened by this pandemic. And those people who are choosing not to be vaccinated are a large part of the reasons why all of these things that matter to us continue to be threatened.”
Much like laws about wearing seatbelts and against driving distracted or drunk, vaccine mandates help the world function. As Faden puts it: “I can’t just go through a traffic light because I’m in a hurry.”
Some experts also hope mandates will encourage vaccination rates to increase.
“It’s going to be more inconvenient for a person on a weekly basis to have to get tested,” Silverman said. “You want this to be as easy as possible for people to say yes to.”
In the US, vaccination rates are shifting back up. In France, thousands protested against Macron’s announcement – as vaccination appointments soared.
“Of course, there’s going to be pushback,” Offit said. “The question is, do vaccine rates go up? And the answer is clearly yes.”