In the spring, a few days before America launched its war on Iraq, a small caravan of civilian cars drove quietly out of Iraq and across the Syrian border. The travelers included two of Iraq's senior biological-warfare scientists and several members of Saddam Hussein's secret service. The security men waited inconspicuously in Damascus before returning to Baghdad. The scientists disappeared for good. Before doing so, however, they met with several members of Hezbollah and gave them a number of small vials. Hezbollah, in turn, conveyed the vials out of Syria. In due course, a number of them reached a refrigerator in a small commercial lab in Tangiers. The lab belonged to Al Qaeda. The vials contained smallpox.

I made up everything you just read. We have no evidence that Saddam possessed smallpox, and no reason to think that Al Qaeda does or will possess it. Yet there is nothing unrealistic about the scenario I sketched. It could happen. What is the United States doing about it? Not enough.

"Not enough" doesn't mean nothing. Von Roebuck, a spokesman for the Centers for Disease Control in Atlanta, said in an interview that all 50 states, plus the District of Columbia and several major cities, now have in place reaction plans in case of a smallpox outbreak. By mail and satellite link, the government has educated clinicians on how to recognize and combat smallpox, which few of them have ever seen in a patient (the disease was eradicated in the wild in the 1970s). The Bush administration is preparing a set of indicators by which to assess the country's preparedness.

What has not happened, however, is this: the widespread vaccination of the health and emergency workers who would be called upon to cope with a smallpox crisis—"first responders," as they are called. The administration had hoped to immunize as many as 500,000 of them by now. As David McGlinchey reported in this magazine last week, "Volunteers have stayed away in droves, and fewer than 40,000 medical workers have been vaccinated." New vaccinations have slowed to a trickle. "The whole thing just lost steam and everybody stopped paying attention, including the administration," says Tara O'Toole, the director of the Center for Biosecurity at the University of Pittsburgh Medical Center.

McGlinchey's article ably details what went wrong: exaggerated fears of the vaccine's side effects; confusing signals from the administration; underfunding; failure to address liability concerns; lack of compensation for health workers made ill by the vaccine or, as a safety precaution, sidelined for up to two weeks after inoculation; above all, the failure from President Bush on down to explain clearly why these vaccinations are important.

Instead, the administration has seemed to switch to defensive mode, downplaying the importance of vaccinations and emphasizing other measures. The CDC's Roebuck stressed that 500,000 was never a formal goal and that many measures, not just immunization, contribute to smallpox readiness. "We still have a lot of work to do on the preparedness side—we freely admit that," he said. "We need to continue to vaccinate more folks." Someone had better tell that to the Homeland Security Department, where they're saying, as a spokesman told McGlinchey, "We feel that we have enough inoculated individuals should an outbreak occur."

Meanwhile, a number of public health types are telling the country to relax about smallpox vaccination. The odds of an attack are very low, they say, and advance immunization isn't necessarily indispensable, and smallpox is only one of many bugs and poisons out there anyway.

Are calls to shelve or down-gear the vaccination effort justified? On a certain set of premises, yes. Unfortunately, those premises are wrong. Here are the facts:

  • Smallpox is not just another disease.
    • It is highly communicable, especially to people tending the ill. It is believed to have been weaponized in large quantities by the Soviet Union. It is about 30 percent fatal and severely disfigures many survivors. It is readily preventable by means of a safe, effective, and available vaccine. After it strikes, however, doctors can do little to help (there is no specific treatment). If you can come up with any other bioweapon that touches all those bases, you get a free box of cigars.

  • Smallpox is not a small threat.
    • It is an indeterminate threat. Which is not at all the same thing.

    Where are the tons of smallpox material that the Soviets are thought to have made? We don't know. Maybe all of that stuff vanished from the face of the Earth. Maybe it is all under vigilant guard at an incorruptible, supersecret Russian facility, where not an ounce of it could escape. Want to bet your life on it?

    No smallpox has been found in Iraq, and as far as we know, Saddam didn't have any. But if he did once possess smallpox, its absence now is not necessarily a good thing. Where might it be? Safely locked up in responsible hands? Bet your life?

    Although we have no idea how large or small the risk of a smallpox attack is, this gives no grounds for complacency, because we are 100 percent sure about something else: America is highly vulnerable to an attack should one occur. A smallpox attack is second only to a nuclear attack on the list of America's strategic vulnerabilities—and for smallpox we have a vaccine. Put it this way: If someone developed a way to inoculate Americans against a nuclear blast, would any responsible person hesitate to mount a major pre-emptive immunization program on the grounds that no terrorist is actually known to have a nuclear bomb right now?

    Although the vaccine itself is risky, the risk is minuscule. (See NJ, 2/1/2003, p. 338.) A few cardiac deaths following recent inoculations seem to have been unrelated to the vaccine. So far, says Michael T. Osterholm, the director of the University of Minnesota's Center for Infectious Disease Research and Policy, the vaccine has proved as safe as expected, if not safer. "No deaths—none—in this country were associated with smallpox vaccination," he said in an interview, "and that was including 500,000 military vaccinations."

  • Immunization is critical,
    • above all for first responders. This year's SARS epidemic proved how fast and far infections can travel in today's world. "When one or two cases of smallpox are documented in one city somewhere," Osterholm says, "there will be thousands of Americans rushing to emergency rooms with rash illnesses thinking they have smallpox." There will be fear, uncertainty (confirming smallpox takes time), and 24/7 news coverage. "We'd better have health care workers who feel confident being on the front line, to see those patients," says Osterholm. Otherwise, "we'll have many health care workers who will not have been vaccinated who will say, 'Look, I'm not going to care for these patients—I just can't care for them.' Every emergency room will be overwhelmed. It'll be like we saw with SARS, with health care workers literally walking off the job out of fear. If anyone thinks we're going to be able to vaccinate all those health care workers in two days while they're also investigating the outbreak—it's not going to happen."

    Toronto is a large city with a modern and sophisticated health infrastructure, yet SARS, which killed or sickened a few health workers while frightening others, "paralyzed a major segment of Ontario's health care system for weeks," according to a recent Canadian report. Compared with smallpox, SARS is a head cold.

  • Too few health workers have been vaccinated.
    • "There's no 'probably,' " says Osterholm. "It's too small now. It is inadequate." O'Toole concurs. Smallpox preparedness, she says, has advanced by "some small increment" since September 11, "but essentially our readiness is not improved since 2001." Among experts, the consensus seems to be that vaccinating the whole country after a smallpox attack, from the current state of readiness, would take not days but weeks or even months.

    Jump-starting the vaccination program may now be difficult. Among health workers, O'Toole and Osterholm say, cynicism and complacency have set in. Looking at the program's poor execution, many people have concluded that the government wasn't serious about vaccinating. Administration statements pooh-poohing the program's stall can only confirm that impression.

    Only one man in America could turn the situation around, and his name is George W. Bush. In Iraq and elsewhere, he has shown what a bulldog he can be when a national security problem engages his full attention. On smallpox, however, he has dropped the ball.

    Imagine, President Bush, how you would look to history if, a year after you left office, America were devastated by a smallpox attack—one for which you left the country underprepared, despite ample knowledge of the nation's vulnerability. Does that get your attention?

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