Vaccine mandates aren’t new. But do they work?

Get vaccinated or face jail time.

That’s the harsh message delivered by the Philippines President Rodrigo Duterte during a televised address on Monday night, to people who are against getting a COVID-19 vaccine. 

It’s not an official policy. It lacks legal grounds. 

Related: Vaccine hesitancy: A nationwide challenge in the Philippines

Still, the frustration with lagging vaccine campaigns in some regions — combined with new surges in cases and the spread of a more transmissible delta variant — is prompting more leaders to move beyond incentives, like free cows and cash, to vaccine mandates. 

Related: Vaccine envy? There’s a German word for that.

Some parts of Pakistan and Indonesia have introduced financial penalties for turning down a vaccine. In the United Kingdom, where the delta variant is rampant, Health Secretary Matt Hancock recently urged members of parliament to do more to improve the uptick in vaccinations. 

“We know that science has given us a solution, we must use this time to protect as many people as we can, as quickly as we can,” he said. “Because even though it’s going at bolstering pace, there are still people we must protect.”  

Hancock then introduced a policy that all care workers in nursing homes must get the jab by October, or they may be moved out of front-line positions. 

Related: The quest for a universal coronavirus vaccine

“I have to say, I’m disappointed that it’s going to be made mandatory. … We live in a democracy, we live in a free world, and I think it’s important that people have the right to refuse something, injections in their body, if they want it.”

“I have to say, I’m disappointed that it’s going to be made mandatory,” said Mike Padgham, managing director of St. Cecilia’s care services in North Yorkshire. “We live in a democracy, we live in a free world, and I think it’s important that people have the right to refuse something, injections in their body, if they want it.”

Padgham said employees absolutely should get vaccinated — in fact, more than 80% of staff across the UK already have — but it’s hard enough to recruit workers and maintain them. He worries a mandate will only make the situation worse. 

Related: After a sluggish start,’vaccine shopping’ in France may lead to waste

Along with governments, businesses and universities are also debating different kinds of mandates for COVID-19. Penalties range from being blocked entry to losing one’s job. 

But mandates are not a new phenomenon.

The US Supreme Court reviewed vaccine policy for the first time in 1905, in the case of Jacobson vs. Massachusetts, explained Lawrence Gostin, a global health professor at Georgetown University.

“The city of Cambridge was requiring all of its residents to be vaccinated against smallpox,” said Gostin, who also directs the World Health Organization’s Center on Global Health Law.

The court ruled in favor of states and the mandate, which involved a hefty fine. In the time since, more than 100 countries have enacted vaccine mandates that are often tied to educational or financial penalties. They’ve helped dramatically reduce the spread of deadly illnesses. 

“You know, the CDC [Center for Disease Control and Prevention] called childhood vaccinations — including mandates — the public health achievement of the 20th century.”

“You know, the CDC [Center for Disease Control and Prevention] called childhood vaccinations — including mandates — the public health achievement of the 20th century,” Gostin said. 

Fast forward to the pandemic, Gostin thinks COVID-19 vaccine mandates — of proven and safe vaccines — may be the way to go to protect certain groups because “we don’t have time to wait with particularly high-risk communities.” 

More than 100 US universities, including his own, have imposed mandates on those returning to campus.

Vaccine requirements must strike a delicate balance between bodily integrity and public health, so they don’t backfire, cautions Julie Leask, a professor at the University of Sydney’s School of Nursing and chair of the WHO working group on behavioral and social drivers of vaccination. 

“…[A] lot of policymakers and businesses and organization managers will see mandates as a quick fix.”

“I’m very concerned there won’t be enough planning around these policies,” said Leask, who thinks sweeping COVID-19 vaccine mandates should be a last resort. “Because a lot of policymakers and businesses and organization managers will see mandates as a quick fix.” 

Vaccines still have to be readily available. People have to trust they’re safe and effective. That requires planning, education, outreach and assurances that lower-income or Indigenous communities aren’t disproportionately impacted. 

Leask has analyzed the way a mix of incentives and mandates improved childhood vaccinations in Australia. It brought people in who were on the fence. For those who were against it no matter what, if they tried hard enough, they could find an exemption. 

That flexibility is important because “those who are already not planning to vaccinate will often dig in. They’ll find other ways around, and may even become more against vaccination,” said Leask, drawing from recent research. 

The World Health Organization urges caution when places are considering different kinds of mandates. 

In Moscow, hospitals are nearing capacity, amid a worrying surge in cases. In response, the mayor announced last week that all state and service sector workers must get vaccinated by mid-August, otherwise they’d risk losing their jobs. 

Many, like Dr. Vasily Vlassov, an epidemiologist at Moscow’s Higher School of Economics, are wary of the more punitive approach. 

Russia was one of the first countries to start a vaccine rollout with its homegrown Sputnik V vaccine. Vlassov, a former adviser to Russia’s Ministry of Health, said it has been rocky and confusing from the start. The vaccine itself hasn’t gone through rigorous, transparent clinical trials, and a majority of people are hesitant to get the shot. 

“We don’t trust the national or regional statistics of the epidemic,” he said. 

About 12% of the population has been vaccinated. Vlassov said for the many who really don’t want it, there’s an easy work around — buying a certificate of vaccination on the internet.

“If you pay a good price, you have the certificate, which will be legally valid.”

This could complicate future efforts to contain the pandemic in Russia, he said.