Pox Americana

Stop Whining, America, and Get Serious about Smallpox

Having lived through the 20th century, Americans know better than to shrug off the threats of ruthless, desperate, and possibly mad dictatorships ("Oh, that's just the way Hitler talks"). Last month, North Korea warned of turning America "into a sea of fire." At the moment, North Korea may have at most two nuclear weapons, with no reliable way to deliver them across the Pacific. How, then, might this little asylum case bring mass death, destruction, and panic to American shores?

Smallpox constitutes one of America's two most glaring strategic vulnerabilities, rivaled only by loose nukes. No one knows who, apart from the Russians, may have smallpox on hand, but North Korea is a leading candidate. The disease is virulently contagious, and it kills about 30 percent of the people who come down with it and disfigures or blinds many of the rest. And North Korea threatens to annihilate America. And Saddam Hussein is capable of who knows what. And America's vulnerability practically begs for an attack or a panic-inspiring threat. All of this we know.

On Jan. 24, Connecticut became the first state to begin immunizing some health care workers against smallpox. The Bush administration hopes to inoculate as many as 500,000 health workers in the next few weeks, and several million more "first responders" (health and emergency personnel) in the months after that. This is good.

But the effort began not with a bang but a snivel. In Connecticut, all of four people showed up to be inoculated. "A growing number of hospitals and medical groups decided not to participate—at least for now," reports The Washington Post. Alabama initially planned to inoculate 12,000 people, but the actual figure looks to be more like 2,000 to 5,000, according to The Post, which adds that Ohio, Colorado, North Carolina and other states "are scaling down their programs." The New York Daily News reports that "some 80 hospitals in 22 states are balking at inoculating their staffs."

Meanwhile, nurses' organizations in California, Rhode Island and Massachusetts advised their members not to volunteer for inoculation. Health care workers' unions are doing the same. The American Nurses Association demanded that the campaign be delayed "until key concerns are addressed," among them "the right of coverage of medical costs associated with receiving the vaccine," "compensation for lost time at work due to adverse effects of the vaccination program," and "protection from job discrimination or retaliation for refusing to be vaccinated."

If health care workers reject vaccination, the effect may reverberate through the general population. The voluntary vaccination of, say, 60 percent of the American public could help reduce the toll of a smallpox attack by more than 90 percent, as recent simulations by the Brookings Institution's Center on Social and Economic Dynamics vividly showed. Two polls in December found, respectively, 59 percent and 46 percent of the public willing to take the vaccine even when apprised by the pollsters of "some risks involved" (59 percent) or "serious side effects or death in a small number of cases" (46 percent—still a plurality). The public's willingness to volunteer for inoculation represents a precious civil-defense asset; health care workers' well-publicized skittishness risks squandering that capital. After all, if the vaccine is too dangerous for my doctor or nurse, it surely must be too dangerous for me.

Are the foot-draggers right? Consider their arguments:

"The vaccine poses real health risks, but the smallpox threat is entirely conjectural." True, there is no proven smallpox threat. Chances are we won't know until the virus is actually released. The issue, however, is not public health but national security. The goal is not to make people healthier than they would otherwise be, which is what public health measures are usually for; it is to make the country less vulnerable to attack and—every bit as important—intimidation. America's strategic vulnerability is clear and present, even if the virus is not. Security is worth something, even at the cost of a few lives.

It's understandable that health workers should think and talk like health workers rather than security strategists. But the Bush administration should think and talk about national defense. Why isn't it making the case, prominently and assertively?

"But there's no compensation program for people who are injured by the vaccine or who miss days of work." True enough, and the Bush administration's failure to create a program is a baffling lacuna. But this does not end the discussion.

To begin with, many people who suffer adverse reactions to the vaccine will be covered by health insurance. Some will qualify for workers' compensation. Private charities can help, too. One way and another, not many people hurt by a smallpox inoculation will die on steam grates. The government should set up a formal program, and it may yet do so (interest is keen on Capitol Hill). But North Korea rumbles now. If, as the American Nurses Association suggests, vaccinations are delayed until every eventuality is provided for, the wait will be long. Possibly too long.

That is the minor point. Here is the major one. Didn't someone once say, in the face of an earlier threat, "Ask not what your country can do for you; ask what you can do for your country"? Didn't many people complain that President Bush failed to ask Americans to do anything more serious about terrorism than go shopping? Well, here is a chance for individual Americans to step up and make a real difference. Some of them will miss work, yes. But have we really reached a point where Americans won't donate a few days of their working lives to help protect their country against a leading terrorist threat?

A few people, of course, will have serious health complications rather than just missed workdays. That is a problem. But the risk of a potentially life-threatening reaction to the smallpox vaccine is between 14 and 52 per million inoculations, according to the Department of Health and Human Services, and the odds of death are one to two per million. By comparison, the chance of dying behind the wheel of a car is about 24 per million drivers per year. In other words, the fatality risk you would assume by taking the smallpox vaccine is about a 10th the risk you assume by driving around, and the reason for being vaccinated seems somewhat more compelling than, say, the need for a Slurpee.

"The real problem is that nonvolunteers can also be infected by the vaccine virus and can be crippled or killed." This is the reservation that thoughtful public health officials voice most often. As The Post reports, "Physicians said their main concern is for patients and family members who might inadvertently be infected by the live-virus vaccine."

The site of the smallpox inoculation on the body can shed vaccinia virus, which, if it infects someone who has a compromised immune system—say, an HIV or cancer patient—can kill in a horrible way. In an interview, John Neff, a pediatrician and infectious-disease specialist at the University of Washington School of Medicine, told me, "If I were to go out and get vaccinated for myself, and I inadvertently infect my spouse or someone I didn't even know had an immune problem, and that person died, I've done a terrible thing." Moreover, even one such case in the national headlines could cause a backlash against not only smallpox vaccination but against vaccines generally.

It is proper to be concerned about this problem. But it is not proper to be paralyzed by it. Working from data that Neff and three of his colleagues recently published in the Journal of the American Medical Association, I figure the odds of dying from "contact vaccinia," as it's called, at two to four per 10 million inoculations. In 2001, by way of comparison, every 10 million licensed drivers caused the deaths of about 300 pedestrians and other nonriders—people who had not voluntarily assumed the risk of getting into an automobile.

Notice, please, that driving a car is on the order of 100 times more likely to kill a bystander than is getting a smallpox inoculation. Yet we do not prohibit driving. Nor do we even discourage it. Nor do we run a national compensation program for pedestrians injured by automobiles. Rather, we recognize that a sensible society puts up with certain small risks in the pursuit of larger goals.

So the people who are foot-dragging on smallpox vaccination are really people who are asking this: "Should Americans be expected to assume a mild inconvenience or a minuscule risk in order to help secure their nation against a fearsome attack?" A country, or a government, that fails to answer that question very clearly in the affirmative is either neurotic about risk or unserious about terrorism. Or both.