Is Smallpox Next?

Not likely, but the consequences would be dire

Now that bioterrorism has been unleashed in America, the natural question is this: What could be next? The most frequently mentioned possibility is smallpox. Unlike anthrax, which is not infectious, smallpox is highly contagious. After exposure, it takes about 12 to 14 days for the disease to incubate, after which it manifests itself as a high fever and aching pains, followed by development of a rash in two days. By the sixth day, pustules form all over the skin; by 12th day, scabs form, leaving scars. Death occurs in the second week.

The disease is spread chiefly through droplets expelled by the coughs and sneezes of infected people. It can also be spread through contact with contaminated clothing and bed linens. Smallpox patients are most infectious during the first week after the rash has appeared. Generally, due to fever and severe body aches, patients are confined to their beds, so people who come into face-to-face contact with them-friends, relatives, health care workers-are most likely to become infected.

For centuries, smallpox was a worldwide scourge that nearly everyone contracted at some point in the course of his or her life. The illness typically killed 30 percent of those infected-and some populations were even more susceptible. After 1492, European diseases, including smallpox, killed 95 percent of the New World's pre-Columbian Indian population, estimates Jared Diamond, professor of physiology at UCLA.

In 1796, Edward Jenner demonstrated that infecting people by scratching their skin with cowpox would protect them from smallpox. He had invented vaccination. After some initial public resistance, the practice began to spread, and in the 20th century, smallpox was eliminated. In 1967, the World Health Organization launched a global campaign to eradicate the disease; only 10 years later, it had succeeded. In 1980, the World Health Assembly recommended that countries no longer vaccinate their populations.

Officially, smallpox virus exists in only two freezers, one at the U.S. Centers for Disease Control and Prevention in Atlanta, Georgia, and the other at the Vector facility in Koltsovo, near Novosibirsk in Russia. Discussions are ongoing over whether those stocks should be destroyed as scheduled on December 21, 2002, thus making smallpox extinct.

The United States stopped vaccinating in 1972. Like many other people of a certain age, I have a small barely discernable scar on my left arm to show that I've been vaccinated. However, immunity declines over time and is generally thought to be no longer effective after 15 to 20 years. Thus, the entire American population-and, in fact, most of the world-is as vulnerable to smallpox as the Indians were before 1492. It is this vulnerability that would make smallpox a frightening and effective weapon.

"The discovery of a single suspected case of smallpox must be treated as an international health emergency," according to the Journal of the American Medical Association's consensus statement on "Smallpox as a Biological Weapon." The good news is that the virus cannot survive more than two days outside of human bodies, so, unlike anthrax, smallpox doesn't lurk around in the environment waiting to infect those unlucky enough to come in contact with it.

How might bioterrorists spread smallpox? Given that the virus can't live outside of human bodies, don't expect to get any in your mail. The low-tech way they might try to disperse the disease is the moral equivalent of suicide bombing: by infecting themselves with the disease and then wandering around sneezing on the people they encounter. The problem with this option is that by the time they would be at their most infectious, they would be flat on their backs writhing in pain. More high-tech terrorists might attempt the relatively difficult task of creating an aerosol spray that they would disperse in crowded places like an airport or subway.

The bad news is that the Soviet Union had a massive secret biological weapons program that operated in violation of the 1972 Biological Weapons Treaty that it had signed. The hair-raising details of the Russian bioweapons program are discussed in Toxic Archipelago, a report issued by the Henry Stimson Center in Washington, D.C. The Soviets apparently succeeded in producing tons of smallpox virus that could be delivered to strategic targets via intercontinental ballistic missile. In the early 1990s, Russian President Boris Yeltsin revealed the biological weapons program and declared that he had shut it down.

Clearly, smallpox is extremely dangerous, but how likely is it that terrorists such as Osama bin Laden's Al Qaeda group have gotten hold of some?

Since smallpox no longer exists in nature, the terrorists would have to acquire it from a laboratory. Although terrorists do not have access to the vials stored in liquid nitrogen in Atlanta and Moscow, are there other undeclared stocks somewhere in the world? Circumstantial evidence points to Iraq and North Korea as possibly having some smallpox on hand. Also, it is possible that a destitute Soviet scientist or two may have sneaked some out of the laboratories before they were closed. (When Russia shut down its biowarfare program, nearly 9,000 highly trained scientists were left unemployed.)

"I doubt that any national government, including Iraq or North Korea, would voluntarily give samples of smallpox to terrorists," says Jonathan B. Tucker, author of Scourge: The Once and Future Threat of Smallpox. Tucker adds, "There is no evidence that Osama bin Laden has any kind of sophisticated biological weapons capability." Why wouldn't Saddam Hussein be willing to give the virus to terrorists who want to attack the United States? "Because he's got a vulnerable population too," says Tucker. "The disease is not easily targetable and it would quickly find its way back to the Middle East."

As for impoverished Soviet scientists handing some virus over to terrorists, Amy Smithson, director of the Chemical and Biological Weapons Nonproliferation Project at the Henry Stimson Center, doubts that it's likely. "I have interviewed dozens of former Soviet weaponeers and even broke, destitute, and out of work, they fully understand the consequences of letting smallpox loose again," says Smithson. "It's not just those targeted who would suffer. Their own family, friends, and country would suffer too. Is that a guarantee? No, but it's simply to acknowledge that former Soviet weapons scientists know what is at stake."

What if terrorists were able to overcome all of these problems and actually release smallpox in the United States? What could the United States do to counter such an attack?

Once a person has been diagnosed with smallpox, he or she will be immediately quarantined and a search for people who may have had face-to-face contact with the patient after the onset of fever will begin. Those people, too, will be quarantined and given shots of smallpox vaccine. As the successful global eradication program demonstrated, vaccinating around the outbreak can control it, so it is not always necessary to vaccinate everyone.

According to Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, the United States has a stockpile of 15 million doses of smallpox vaccine. Some preliminary tests show that vaccine diluted to one-tenth strength remains 70 percent effective, and a larger study is being undertaken to determine vaccine effectiveness when diluted to one-fifth strength. Such dilutions could more or less immediately supply enough vaccine to immunize between 75 million and 150 million Americans. In the meantime, the federal government is contracting to buy an additional 300 million doses of vaccine by the end of next year. Health officials strongly recommend against re-instituting mandatory smallpox vaccination because of the substantial risks of side effects. But once the vaccine stockpile is in place, even the unlikely prospect of a smallpox attack recedes as a serious concern.

Keep in mind that although the United States is not as prepared as it should be to defend against a smallpox attack, it is far better prepared than most of the rest of the world, especially including the homelands of most of the Al Qaeda terrorists.

What's the bottom line? "I don't think people should be too worried about smallpox," says Tucker. "I'm more worried about anthrax than smallpox. Someone clearly got access to dried anthrax."

But as frightening and appalling as the deaths of American postal workers and journalists are, the public should keep the danger in perspective. So far, three Americans have died of inhalational anthrax: one employee of American Media, Inc. in Florida, and two postal workers in Washington, D.C. Several thousand people in New York and Florida newsrooms and in congressional offices have been tested for exposure to anthrax and are being treated with antibiotics to guard against any possible onset of infection. By comparison, every year some 20,000 Americans die of influenza that they could easily prevent if they would only get vaccinated.

Distributing anthrax through the mail is a very crude delivery device that does not threaten the health of whole communities. The anthrax attacks are designed to terrorize. If the terrorists were really trying to assassinate people, they wouldn't warn, as the letter to Senate Majority Leader Tom Daschle reportedly did, "You've been exposed to anthrax. You're going to die." After all, such a warning allows the recipient time to get proper medical treatment in time to prevent the disease.

Finally, the Bush administration has just reached an agreement with Uzbekistan to clean up vast quantities of anthrax spores dumped by the Soviets on an island in the Aral Sea. This is a good first step, but it is clearly past time that the Americans and Russians worked together to lock up and then clean up all of the old Soviet biological, chemical, and nuclear weapons complexes.