Smallpox is the most deadly disease in our species' history. Variola virus causes this disease and humans are the virus' only natural host. It is transmitted person-to-person, most commonly through the air. Infected people exhale the virus from blisters in their mouth, and anyone who comes within 10 feet of a smallpox victim can inhale the aerosolized virus and catch the disease. There are no currently available anti-viral measures that doctors can use to treat smallpox. Antibiotics don't work. Vaccination, however, protects a person from contracting this disease. More than 300 million people died from smallpox from 1900 to 1978, when the last case in the world occurred. The last case in the United States was in 1949. Doctors and public health officials eradicated the disease by mass vaccination. People in the U.S. stopped being vaccinated for smallpox in 1972, when more deaths from vaccination occurred than from the now nonexistent disease. (In 1968, the last year for which data is available, 9 deaths occurred in the 14.2 million people who were vaccinated.) But laboratory stocks of variola virus, preserved ostensibly for research, were not destroyed. Before it collapsed in 1991, the Soviet Union had its state-employed microbiologists grow, in the embryos of chicken eggs, vast quantities of smallpox virus for use as a biological weapon 100 tons of it. There is a high probability that Iraq has acquired a stockpile of the virus and has recruited laid-off Soviet scientists to weaponize it.
All Americans are susceptible to smallpox. Forty percent of the population, born after 1972, has never been vaccinated. The rest were vaccinated more than thirty years ago, and they are also susceptible because smallpox vaccine loses its effectiveness in most people after 5 to 10 years. But if the Federal government, which controls the vaccine (paid for with tax dollars), releases it and permits mass vaccination for smallpox on a voluntary basis, Americans would be protected against smallpox. Should the government decide whether or not to permit voluntary "pre-event" vaccination, or should Americans themselves decide whether or not to have the vaccine?
As conceived by America's Founders, government's main function is to protect the liberty and property of its citizens. Self-ownership underpins a truly liberal society. Individuals are free, within the constraints of honoring their contracts and not encroaching on other persons and their property, to do what they want. From this perspective, each citizen should decide whether he or she wants to be vaccinated. But many people today who call themselves liberals hold a different view of government and the state. They think the state must take charge of the health and welfare of its citizens.
The Advisory Committee on Immunization Practices (ACIP), in the government's Center for Disease Control and Prevention (CDC), addresses vaccination policies. This 15-member committee issues "recommendations" on vaccinations, which more often than not become compulsory state policy, as, for example, requiring doctors to inoculate newborns with hepatitis B vaccine. Most states have adopted this policy and have made hepatitis B vaccination mandatory, even though there are doctors, Dr. Jane Orient among them, who have shown that children are a hundred times more likely to suffer adverse effects from the vaccine, including death, than they are to catch hepatitis B a disease that rarely occurs in children and is found mainly in drug abusers, people with multiple sex partners, and through occupational exposure to blood products.
The ACIP updated its "recommendations" on smallpox vaccination in its June 2002 Draft. They are: 10 to 20,000 medical workers "pre-designated by the appropriate bioterrorism and public health authorities" should be vaccinated for smallpox. The committee opposes voluntary mass vaccination. Its parent agency, the CDC, controls all the smallpox vaccine in the country, enough, properly diluted, to vaccinate all 288 million people in the United States. The ACIP contends that the vaccine should not be made available to the general public because, in the committee's opinion, "the potential benefits of vaccination do not outweigh the risks of vaccine complications." People who disagree with this assessment and think that the benefits of vaccination do indeed outweigh its risks and want to be vaccinated are out of luck. The CDC keeps a tight lid on its stockpile of smallpox vaccine.
Smallpox has an ancient lineage. Egyptian writings 5,700 years old describe this malady, and there is a mummified pharaoh in the Cairo Museum (who died in 1157 B.C.) that has pustules indicative of smallpox on its face and hands. According to Jonathan Tucker in Scourge: The Once and Future Threat of Smallpox, when Columbus discovered America in 1492 the native population of North and South America was around 72 million. By 1800 it had decreased to 600,000, in large part because of smallpox, which Europeans brought with them. Queen Elizabeth I, George Washington, and Abraham Lincoln contracted this disease. Smallpox left Elizabeth with disfiguring facial scars and bald, requiring her to wear a wig and heavy makeup for the rest of her life. America fought the Revolutionary War in the midst of a smallpox epidemic, which British forces exploited to their advantage (by sending infected civilian refugees into the American lines).
A person who comes in contact with a smallpox victim need inhale only a few smallpox virus particles to become infected. Russian scientists found in their laboratory tests that five viral particles were sufficient to infect 50 percent of animals exposed to aerosols of smallpox. Once having gained a foothold in its new human host, the virus utilizes that person's cellular machinery to make countless copies of its genome. Following seven to seventeen days of incubation, typically on the twelfth day, the disease begins with the abrupt onset of flu-like symptoms of fever, headache, backache, nausea, and vomiting. These nonspecific symptoms are followed two to three days later with a skin rash that starts out as red spots, initially on the face and hands, and then spreads over the entire body. The spots swell into blisters that over a period of about a week fill with pus. Scabs form after the pustules swell to the point that they damage the skin. When the scabs fall off the survivor is left with pockmarks (pitted scars), which are most severe on the face. Smallpox is infectious over about a three-week period, beginning either with the onset of fever or the rash (investigators disagree on this) until the pockmarks heal. A smallpox victim is likely to be infectious before the rash appears because throat swabs taken in the pre-eruptive period contain the virus.
The overall mortality rate for smallpox in unvaccinated people is 30 percent 40 percent in young children, 20 percent in adults, and 30 percent or more in the elderly. (Flat-type smallpox has a 95 percent mortality rate; and a mild form of the disease, variola minor, has a 1 percent mortality rate.) Boston had its final smallpox epidemic in 1901 (when the average life expectancy in the U.S. was 47 years and there were fewer elderly and immunosuppressed people in the population than today). Eighty-two deaths occurred in 754 previously vaccinated people (11 percent) and 188 deaths in 842 unvaccinated people (22 percent). The last two epidemics in the U.S. occurred in 1946 and 1947 in Seattle and New York, respectively. In Seattle, 51 people contracted the disease before the outbreak could be contained and 16 died (31 percent). In New York, where there had been no cases of smallpox for 20 years, 12 people came down with the disease and two died. Hourly bulletins were broadcast on the radio, and frightened New Yorkers queued in blocks-long lines to be (re)vaccinated at 250 vaccination stations set up at police stations, schools, offices, and factories. The 250,000 doses of vaccine that the city had on hand quickly ran out, and city officials issued urgent appeals for more, which it obtained from military, pharmaceutical, and other sources from around the country. The Commissioner of Health reported that health workers vaccinated 6,350,000 people in the city over a four-week period.
In 1990, when the U.S. was planning to invade Iraq the first time (in 1991), analysts at Armed Forces Military Intelligence reported that Iraq had a "mature offensive BS [biological weapons] program," one that could deliver biological weapons from aerosol generators carried on trucks, boats, or helicopters; in artillery shells and missiles; and from aircraft. At the time, according to Judith Miller and coauthors in Germs: Biological Weapons and America's Secret War, the CIA issued a report titled "Iraq's Biological Warfare Program: Saddam's Ace in the Hole." In 1990 the bioweapons of greatest concern to military planners were anthrax and botulinum toxin. Now, in 2002, it is smallpox.
The full extent of the Soviet bioweapons program in the 1970s and 80s, which focused on smallpox, is now known. Ken Alibek (Kanatjan Alibekov), one of its directors, reveals its extent in Biohazard: The Chilling True Story of the Largest Covert Biological Weapons Program in the Worldu2014Told From the Inside by the Man Who Ran It, published in 2000. With the breakup of the Soviet Union the thousands of scientists working in this program became unemployed and some of them, along with their families, destitute. Both their services and stocks of variola virus came onto the black market. Richard Preston in "Demon in the Freezer," published in The New Yorker in 1999 (he has written a book with that title that will be published in October 2002), points out this irony with regard to the eradication of smallpox: "The eradication [with the Soviet Union's help] caused the human species to lose its immunity to smallpox, and that was what made it possible for the Soviets to turn smallpox into a weapon rivaling the hydrogen bomb." He writes, "The Central Intelligence Agency has become deeply alarmed about smallpox" and reveals that the U.S. government keeps a classified list of states that it suspects has weaponized smallpox. Iraq is on the list (along with Russia, China, Pakistan, N. Korea, and Cuba).
The November 16, 2001 issue of Jane's Foreign Report (#2664) says that a reliable source tells them that Iraq bought smallpox virus from Russian scientists, who now work there; and "agents [are] provided with smallpox to spread abroad." Jane reports, "Our informant reckons that Saddam might try such an attack only if he felt the game was over and he faced death."
The Federal government, in its September 16, 2002 Smallpox Vaccination Clinic Guide, outlines how state and local public health authorities can set up and staff clinics to carry out "voluntary, large-scale, post-event smallpox vaccination" should a "smallpox outbreak" occur. The 48-page guide states that "once Federal authorities have authorized release of vaccine" it could distribute 280 million doses around the country within five to seven days, and by following the template provided in the guide local public health officials (utilizing a staff of 4,600 people) could vaccinate 1,000,000 people over a seven-day period. This plan would supplement standard measures of surveillance and control and "ring vaccination" (tracking down and vaccinating every person who has been within ten feet of a smallpox victim). Health officials used these techniques to eradicate smallpox.
Ring vaccination in natural outbreaks of smallpox worked because people infected with smallpox virus can escape the full effects of the disease and not pass it on if they are vaccinated in the first four days of the infection. "Post-event" mass vaccination is predicated on this fact. This most likely would not be the case in a biological attack. The strain of smallpox virus that the Russians weaponized and what Iraq most likely has is the India-1 strain, which is highly virulent. Soviet laboratory tests showed that monkeys exposed to an aerosol of this strain would contract smallpox in 1 to 5 days rather than the usual 7 to 17 days with other strains.
In the last smallpox outbreak that occurred in this country, the one in New York in 1947, a man who became infected with smallpox in Mexico rode a bus to New York while he was in the prodromal phase of the disease and developed a skin rash (which doctors misdiagnosed) when he arrived in the city. That single, naturally occurring case, when it was discovered to be smallpox in people that he had infected, created havoc. In a biological attack a likely scenario would be that a terrorist, carrying an aerosolized can like that used for hair spray, would spray freeze-dried smallpox virus in a shopping mall, airport, or sports stadium. Aerosolized smallpox sprayed in the men's rooms of a dozen airports around the country by a group of terrorists would, two weeks later in an unvaccinated population, create a crisis of unimaginable proportions and turn "post-event" mass vaccination into a logistical nightmare.
When the U.S. invades Iraq the likelihood that America will be attacked with smallpox will rise substantially. The risk that there will be a smallpox attack and of dieing in it will be much greater than one-in-a-million (the mortality rate for revaccination in people who have been previously vaccinated is one in 10 million). Federal authorities should heed the advice of the Senate's only doctor, Senator Bill Frist, M.D. (a fellow cardiac surgeon). In his book When Every Moment Counts: What You Need to Know About Bioterrorism he describes smallpox as "the scariest bioterrorism nightmare." He advocates voluntary, preexposure, mass vaccination and makes the point that "Americans should be able to decide for themselves whether to accept the risk of inoculation," adding, "I believe the threat of a smallpox attack outweighs the risk of providing smallpox vaccinations to a well-informed public."
Why will Federal authorities not release the vaccine to Americans who want to be vaccinated? They are concerned that people with skin disorders, like eczema, and people with immune system deficiencies who have cancer, organ transplants, and AIDS might inadvertently get vaccinated. Such people are at an increased risk for an adverse reaction, including death, and should not undergo vaccination. (This includes pregnant women and young children.) But as Dr. William Bicknell points out in his article in the New England Journal of Medicine titled "The Case for Voluntary Smallpox Vaccination," an increased level of immunity in a vaccinated population will "reduce the overall risk of infection among immuno-commpromised persons in the event of an attack." Also, more careful screening on a patient-by-patient basis can be done in a pre-event setting to avoid vaccinating people with immune system deficiencies than would be possible in a crisis atmosphere after a biological attack. Smallpox vaccine is a live virus (vaccinia virus). People who are inoculated with it can spread virus particles at their vaccination site to others in close contact with them, particularly if they do not observe standard precautions of keeping the site dry and bandaged until the scab falls off and washing one's hands thoroughly after changing the bandage. Secondary infection contact rarely happens, but the CDC obviously does not want to be confronted by an irate AIDS Lobby protesting its pre-event release of the vaccine if a person with AIDS should die from a vaccinia infection acquired by contact with a person who has been recently vaccinated.
If the government refuses to release smallpox vaccine to the general public, there is still a way to be inoculated against smallpox. One can be vaccinated "arm-to-arm." We can, if we have to, vaccinate ourselves the way people sometimes did it in the 19th century.
Edward Jenner discovered smallpox vaccination in 1796 (after a milkmaid told him that cowpox, which she contracted from a cow's utter, protected her from smallpox, and he then noticed that milkmaids rarely exhibited the facial scars of smallpox). Absenting cows with cowpox to provide material for inoculation or refrigeration to store and transport stocks of it, people would transfer the vaccine from one person to the next arm-to-arm. The Spanish brought smallpox vaccine to the New World this way. A group of orphans were recruited for the long voyage, and two children were vaccinated shortly before departure. When cowpox pustules developed on their arms the ship's doctor would take material from their lesions and use it to vaccinate two more children, repeating this procedure each time new pustules formed in successive children until they reached Venezuela, with yet two more children providing an aliquot of active vaccine for people in South America.
The government plans to vaccinate military personnel and health care workers (officials have not yet decided how many, but it will be somewhere between 20,000 and 500,000). These people could provide a source of active vaccine for their family and friends arm-to-arm reminiscent of those orphan children bringing smallpox vaccine to the New World. The technique of vaccination is fairly simple (and it does not require a bifurcated needle).
If you cannot obtain vaccinia vaccine one way or another, a devastating biological attack has occurred and smallpox is rampant, in a worse case scenario you can do the kind of vaccination that people employed for centuries before Jenner. That is variolation. Rather than have to suffer the disease with its 30 percent mortality rate and disfiguring facial scars, people inoculated themselves with the smallpox virus itself obtained from a pustule on a smallpox victim. Smallpox introduced through the skin rather than the lungs results in a much-attenuated disease, with only pustules forming around the inoculation site. Variolation, known as "buying the smallpox," has a fatality rate of 1 percent, much better odds than with the full-blown disease.
One thing we must do, especially with the prospect of a biological attack looming, is to maintain optimum health and to keep our immune system strong. This will improve the odds that we will survive it. Read Dr. Russell Blaylock's booklet Bioterrorism: How You Can Survive. I summarize his recommendations, and offer others for good health, in an article I wrote with Linda Miller.
Let us hope that our government leaders will release smallpox vaccine for voluntary, pre-attack, mass vaccination.
September 26, 2002