Smallpox, considered to have been the worst disease known to man, is the only one ever to be eradicated. That is an unparalleled accomplishment of progressive medicine, organization and worldwide commitment. In the horrifying, potentially cataclysmic new world of terrorism, it may also be temporary.
Smallpox is a contagious viral infection, believed to have begun in 10,000 BC, in the world's first agricultural settlements in Asia and Africa. Smallpox is deadly, estimated to have been responsible for a half million deaths in the twentieth century alone, and that is with an estimated death rate of only about a third of those infected. Survivors may be disfigured or blinded.
Smallpox is currently incurable. There is no treatment, but preventive vaccination can be effective within up to four days of exposure. Vaccinations are believed to maintain full potency for three to five years with some protection extending to 20 years, but actual data are not reliable.
The only vaccine in use, virtually unchanged since it was developed in 1796, is itself quite dangerous. Historically, for every million people vaccinated, there were up to 52 life-threatening complications and up to two deaths; hundreds suffered some symptoms of illness. All adverse incidences would most likely rise today, depending upon complex variables that include the effect on segments of the population with weakened immune systems and skin problems such as eczema.
Researchers overseeing recent clinical trials of smallpox vaccine in healthy, college-age volunteers have been disconcerted by the array of side effects, including bed-ridden days, considerable swelling, high fevers and flu-like symptoms, some requiring antibiotics.
Of the trials, Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases, said, "In the thirty years since we had routine vaccination, the public's tolerance level has gone way down." Most medical personnel in the U.S. today have never administered the vaccine and have no experience with the side effects.
Smallpox is spread through respiration in face-to-face contact and direct contact with infected bodily fluids. It can be carried on bed linens, clothing and possibly on letters. Airborne transmission distances are publicly unknown, as are characteristics of weaponized smallpox. Smallpox has an infection rate similar to chickenpox.
Even those who are successfully vaccinated are contagious for several weeks, as vaccination sites shed virus. In most cases, reasonable care (such as keeping the vaccination site covered) can reduce that contagion, but there are many variables, many unknowns that could be compounded by massive emergency vaccinations. Children, for example, who might scratch a vaccination site and then rub their eyes, could be blinded.
The last known case of naturally occurring smallpox was in Somalia in 1977, followed by two British laboratory exposure cases in 1978. No case has occurred in the U.S. since 1949. Following the declaration of smallpox eradication by the World Health Organization in 1980, mass vaccination of civilian populations ended.
During the 1980s, all official worldwide samples of the smallpox virus, preserved as seed cultures, were to have been destroyed or transferred to two ultra-secure facilities, one in Atlanta, Georgia, one in Siberia. By 1999, even those samples were to be destroyed, to avoid accidental or deliberate release, but fear of having no research capability with the live virus has postponed disposal.
Since there was never any certification or enforcement of the smallpox virus disposal program, no one knows the extent to which undocumented samples exist, where they are or who may be developing them as possible weapons of bioterrorism.
U.S. intelligence reports suggest that undocumented smallpox cultures exist in four countries: Iraq, North Korea, Russia and France. If an active French research program actually exists, it is believed to be defensive, but is nonetheless illegal under current conventions, a matter of some sensitivity given France's opposition to war with Iraq. There appears to be some evidence that Osama bin Laden was pursuing weaponized smallpox development, but it is not believed that he has succeeded.
Until 9-11, smallpox was publicly discussed only as a horrific historic epidemic. The 9-11 attacks, and their aftermath, have forced us to confront the unthinkable. Whether the deliberate release of smallpox poses risks great or small, to whom and how many depends upon the possible scenarios one postulates and vary dramatically from country to country. When contemplating the acts of madmen, even remote risks are not comforting. One authority has referred to smallpox as "the biological equivalent of the nuclear bomb" because it spreads itself until stopped.
In the context of risk, just this week reports from Germany provide some insight into what intelligence agencies understand about smallpox development in Iraq. As a result of German Chancellor Gerhard Schröder's opposition to war with Iraq and the weakened political standing of his Social Democrat party, leaders of other parties have begun to charge that Schröder has been minimizing the risk from Iraq. According to The New York Times, they cite "classified German intelligence information that Iraq possesses the smallpox virus...."
Indeed, Der Spiegel is reporting that Germany's Health Minister, Ulla Schmidt, in a hitherto secret memorandum, has recommended that Germany stockpile smallpox vaccine against terrorist threat.
The President of the United States obviously believes a threat is serious enough to warrant mandating the vaccination of critical military personnel and requesting voluntary vaccination of approximately half a million health workers, to be followed by vaccination of 10 million more emergency responders (police, firemen, ambulance personnel) to provide an immune front-line force in the event of attack. There is currently no plan to vaccinate the civilian population, and to do so immediately would require dilution of existing vaccine stocks.
Under most scenarios, there should be no need to vaccinate massive numbers of the civilian population. The disease was finally conquered by so-called ring vaccination programs, working outward from the infected through concentric rings of those who were or could be exposed. Yes, some of us would be infected by a first strike, however that might come, but probably fewer than would suffer from full emergency vaccination of the population. When 12 cases of smallpox were diagnosed in New York City in 1947, six million people were vaccinated in just three weeks. Two people died from the smallpox, three from the vaccine. Yet many more undoubtedly would have died or have become seriously ill without the vaccinations.
Underscoring the certain inherent risks of vaccination to subjects, as well as the risks of vaccination contagion, against the hazy specter of terrorist threat, health workers and hospitals are balking at the vaccination program. As of last week, the prestigious Children's Hospital of Philadelphia and at least 80 others were saying no to the program. The American Federation of State, County and Municipal Employees, the union which represents about 350,000 health care workers, wants a delay in the program while worker compensation issues are determined.
We have become the most risk-averse nation on earth, with many citizens believing sincerely that it is the job of the government to protect us against any risk. It can't generally, and in the case of the deliberate release of smallpox, there simply is no risk-free alternative, presenting a collective test of individual responsibility like none we have recently confronted.
We are not now, as a nation, prepared to meet that responsibility. As a research survey conducted by the Harvard School of Public Health indicates, most of us are woefully ignorant about smallpox, with 78 per cent believing there is effective medical treatment once the disease has been contracted.
There is every hope that a population-wide smallpox vaccination program is unnecessary, but if it is, as columnist Charles Krauthammer has chillingly pointed out, it may be mandatory. Faced with the devastation of a society, individual freedom must give way to individual responsibility, for without the latter, the former cannot exist.February 6, 2003
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