At University Hospital Salzburg, intensive care doctor Andreas Kokofer has been observing the surge of Covid-19 infections with a grim inevitability. With cases having reached a daily record high of 15,809 on November 19, Kokofer and colleagues are bracing themselves for an influx of patients.
The state of Salzburg is a particular hotspot of the current outbreak, with 1,731 cases per 100,000 people over the past seven days, compared to 1,110 across Austria as a whole. With the situation expected to worsen in the weeks to come, hospital administrators across the region have begun to consider the possibility of making tough decisions over which Covid-19 patients will qualify for intensive care, and which will not.
So how has Austria ended up in such a dire predicament, while many countries are planning their exit strategies from the pandemic? The reasons are multifold, from waning levels of immunity to a social and cultural storm, driven by long-standing political divisions, that has led many Austrians to reject the Covid-19 vaccines.
Crucially, what Austria is experiencing could soon hit scores of other countries—and it all comes down to a precarious balancing of the numbers. As the crisis threatened to get out of control, Austrian chancellor Alexander Schallenberg was forced into a decision that seemed unthinkable just a few weeks ago. As of Monday, the country has entered a month-long national lockdown, ushering in the return of restrictions many hoped would be gone for good. Just like in 2020, the Austrian population has been asked to stay at home and only leave the house for essential purposes. Schools remain open, although parents have been asked to keep their children home if at all possible.
The decision has been met with anger in certain corners of the country. Last weekend, 40,000 people took to the streets in Vienna, some carrying provocative placards likening Schallenberg to Nazi leaders.
But while doctors say the current crisis isn’t comparable to the very early days of the pandemic, they remain deeply concerned about how the health care system will cope over the coming weeks. “The situation is tight,” says Kokofer. “We’re having to cancel planned cancer and cardiac surgeries. The lockdown gives us some hope that the numbers will reach a level where it stabilizes.”
While these new restrictions have hit many people in Austria unexpectedly, experts say the crisis has been brewing for some time. According to Eva Schernhammer, an epidemiologist at the Medical University of Vienna, the onset of winter and people moving indoors has made it easier for Covid-19 to spread. Immunity levels are also starting to wane among those who were vaccinated earlier in the year, making them more vulnerable to the Delta variant.
Schernhammer suspects that this is a particular problem for Austria, which has one of the lowest vaccination rates in Western Europe: 65.7 percent of the population is fully jabbed, a rate lower than that of the United Kingdom (68.7 percent), France, Italy, and Germany. In comparison, Portugal has one of the highest vaccination rates in Europe, with 86.9 percent of its population fully immunized. As of November 22, the daily tally of Covid-19 cases per million people was 145 in Portugal, compared to 1,527 in Austria.
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Schernhammer believes the problem has been exacerbated by Austria’s decision to wait six months before allowing fully vaccinated individuals to get booster shots, which is in line with the World Health Organization’s recommendations. She says Austria should have begun administering boosters as soon as it became clear that cases were rapidly rising. “If you do have high case numbers, you may not have the time to wait for six months,” she says. “Hopefully, what we’re going through is a warning to other countries to make sure they accelerate the booster shots.”
But Austria is also grappling with simply getting more of the population vaccinated in the first place. Vaccine hesitancy has been a growing problem in recent years, with increasing numbers of Austrians choosing to decline the annual flu jab. Andreas Bergthaler, a virologist at the Austrian Academy of Sciences, has observed a link between regions of Austria with low Covid-19 vaccine uptake and high rates of the disease. “The vaccination rates in the provinces of Salzburg and Upper Austria seem to correlate, at least partially, with the high infection numbers,” he says.
To fully understand the rise of vaccine hesitancy within Austria, you need to delve into the country’s fragmented political landscape. Austria is currently ruled by a Conservative-Green coalition government, which is pro-vaccination, but both the far-left People-Freedom-Fundamental Rights (MFG) party and the far-right Freedom Party have been vociferous in their opposition to Covid-19 vaccines. Florian Bieber, director of the Center for Southeast European Studies at the University of Graz, says that many of the concepts promoted by these two parties aim to foster distrust in the pharmaceutical industry. Instead they point to the teachings of early-twentieth-century philosopher Rudolf Steiner—a figure with an enduring influence in Austria—who believed in homeopathy and natural remedies of curing disease, as opposed to medicines and vaccines.
“I think it's those two groups together, which make up for the bulk of the skeptics,” says Bieber. “The Freedom Party, which used to be in government until a year and a half ago, has been promoting alternative medicine and conspiracy theories, while the MFG, which is the alternative green electorate, has often declared that the state is too authoritarian.”
Bieber says widespread government distrust among supporters of these parties can easily spill over into willingness to buy into conspiracy theories that encourage vaccine hesitancy. He says it’s notable that the Freedom Party is particularly popular with voters in the Salzburg and Upper Austria regions, where cases have risen sharply in recent weeks. “The Freedom Party has been around since the 1950s and getting double-digit results for decades,” he says. “So they are drawing on a very stable electoral base, unlike other far-right parties across the continent. And it’s antiestablishment, with a lot of resistance to the state campaigns.”
The link between politics and the anti-vaccination movement has been shown in surveys. One conducted in August by Schernhammer found that only 46.2 percent of respondents trusted the Austrian government to provide safe vaccines. Unwillingness to be vaccinated was highest in women and younger Austrians, and in particular those in favor of opposition parties, or those who had abstained from voting in the last election.
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“These are people who either reject the political leadership of the country or the political system altogether,” Schernhammer says. “And maybe these factors come together in the person who rejects the corona measures, but also rejects the vaccine, and does not care to vote.”
In contrast, scientists think one of the reasons that Portugal—a country that ranks among the world’s leaders in Covid-19 vaccinations, with 87 percent of its population fully vaccinated—has been so successful with its vaccine rollout is because it was kept separate from politics. Rather than government ministers, the Portuguese vaccine campaign was led by Vice Admiral Henrique Gouveia e Melo, a public figure with no political affiliations.
Epidemiologists in the United States are now concerned that a combination of winter, waning immunity, and ongoing vaccine hesitancy in different states could mean the situation in Austria is a portent of what’s to come. “Austria’s struggles are not unexpected,” says William Hanage, an epidemiologist at the Harvard T. H. Chan School of Public Health. “There is a message here for other poorly vaccinated areas around the world. There is intense opposition to public health interventions in a lot of the US, and unfortunately that includes a lot of the places with low vaccination rates.”
Austria’s leaders have now attempted to take matters into their own hands through a new mandate that will make vaccination compulsory from February 1, 2022. Authorities will offer appointments for anyone yet to be vaccinated, with penalties of up to €3,600 ($4,055) if they still refuse to comply. For individuals who are already double vaccinated, there will still be fines, of up to €1,500, if they refuse to have a booster shot.
So far only Indonesia, Micronesia, and Turkmenistan have introduced population-scale vaccine mandates. While other countries with low vaccination rates may choose to follow, public health experts believe this could have far-reaching consequences. One possibility is that it will open the door for further mandates, particularly for childhood vaccinations. France, Italy, and Austria have all introduced legislation in recent years penalizing parents who do not get their children vaccinated against common diseases such as polio, chicken pox, and measles.
But with Austria and potentially many other countries facing an incredibly tough second winter with Covid-19, it may come down to balancing concerns about vaccine mandates with other issues, ranging from the economic and social consequences of the pandemic to the effects of school closures on child development. “You have to start weighing what is more costly: a vaccine mandate or further lockdowns,” says Schernhammer. “The mandate is not supposed to start before February, and my hope is that most people decide on their own to get vaccinated by then.”
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