Bush administration wants
the nation to embrace a potentially dangerous mass-vaccination
plan to thwart a smallpox attack. But is the threat real,
box of Marlboros is placed under the hood of a trash can
in the food court at the Crossroads Mall in Oklahoma City.
Hidden in the cigarette case is an aerosolizer—a credit-card-thin
device that emits invisible, odorless bursts of mist over
a few hours. Roughly 100 shoppers cross paths with the mist
before the device expends its supply. For the purpose of
this exercise, that is more than enough.
A week later, officials from the Centers for Disease Control
and Prevention are called in from Atlanta to confirm 20
suspected cases of smallpox at Oklahoma City’s Deaconess
Hospital. Since the disease was eradicated in nature more
than 20 years ago, doctors presume the illnesses are from
a biological attack using smallpox—a highly contagious,
easily transferable disease known to kill one in every three
As word of the smallpox attack is reported in the local
media, emergency rooms citywide are flooded with the infected
and those fearful of infection. Many unvaccinated hospital
workers begin skipping shifts. Gov. Brad Henry requests
that his state’s entire population be vaccinated, and activates
the Oklahoma National Guard.
Nine days after the presumed exposure, there are 20 lab-confirmed
and 14 suspected smallpox cases in Oklahoma City, along
with nine suspected cases in Georgia and 10 in Pennsylvania.
As the smallpox vaccine is being delivered, smallpox patients
and suspected cases are held in local hospitals that have
been converted into quarantine centers. But the isolation
is not forcibly imposed. A few of the quarantined, scared
and infected, sneak out of the hospital to be with family,
bringing the disease with them.
As the scenario progresses, there are 2,000 smallpox cases
in 15 states with 300 deaths two weeks after the presumed
first exposure. The national news media show mothers carrying
their children, screaming for the vaccine before the riot-
gear-clad row of national guardsmen defending a vaccination
clinic. States have closed their borders to highway and
airline travel. Schools close; sporting and other public
events are put on hold. Many countries close their borders
to incoming shipments of U.S. goods, and the impact
to the economy is feared to be in the billions of dollars.
weeks after the attack, a second generation of the disease
surfaces, and the number of cases skyrockets to 14,000 infected,
confined to 25 states, among them densely populated urban
centers like New York City and Los Angeles. Smallpox experts
project third and fourth generations of the disease and
deaths in the millions until it can be contained via vaccination.
But none of this is real. It’s all estimation and speculation.
Fiction. It’s Dark Winter, a contrived scenario carried
out over a few days in the summer of 2001 by a number of
public-health organizations to explore the nation’s preparedness
for a smallpox attack. Through the simulation, Dark Winter
participants discovered that the United States—with a medical
community ignorant of the disease and a highly mobile, unvaccinated
population—would be all too susceptible to a smallpox attack.
As stated in Dark Winter, defense analysts and intelligence
experts have long speculated that smallpox samples were
snuck out of Soviet Union bioweapons labs upon that nation’s
collapse a little over a decade ago. Though the Bush administration
has been quick to spin the National Security Advisory color
wheel and put the public on notice, the president and his
men have done little to corroborate any of the alleged smallpox
Though officials in Washington have repeatedly insisted
that there is no evidence showing that the United States
faces such a smallpox threat, plans to prepare the country
for biological attack have sped up dramatically post-Sept.
Last July, federal officials announced that the U.S. government
plans on vaccinating 500,000 health care and military workers,
up from 15,000 in earlier plans. In September 2002, the
CDC instructed every state to be prepared to vaccinate every
U.S. citizen within a week’s notice. And in December 2002,
President Bush unveiled a highly controversial smallpox
vaccination program, asking 10 million U.S. health care
and military personnel to volunteer for one of science’s
most dangerous vaccines.
The president’s proposal calls for the vaccinations to be
carried out in three stages over 90 days, and the first
phase began in the handful of complying states a few weeks
ago. Sixteen pre-first responders—those who would vaccinate
the vaccinators—received their shots in New York earlier
this month at undisclosed locations.
As the Bush administration is not being forward with the
information, one can only guess that the proposal is based
on simulations like Dark Winter and intelligence about leaked
smallpox stocks. Skeptics have speculated that the administration
might have more sinister motives, such as keeping the American
public in a constant state of fright or lining the pockets
of drugmakers. Either way, the administration has not been
willing to offer evidence to convince the American public
that the smallpox scenario described above is plausible.
Presently, smallpox vaccinations are performed in the same
manner they were when routine inoculation ceased in the
United States in 1971, and are based on the same science
that was employed when the vaccine was discovered in the
To boost the immune system’s ability to ward off smallpox,
humans are infected with a live virus called vaccinia, a
relative of smallpox. Both are family members of the group
of viruses referred to as poxviruses, and vaccinia toughens
up the human immune system to a smallpox onslaught. Vaccinia
is actually smallpox for cows, or cowpox—and cowpox, too,
can be dangerous to humans.
According to the most recent information on mass smallpox
vaccinations, 14 to 52 life-threatening illnesses and 49
to 935 serious but non-life-threatening illnesses are estimated
per million vaccinated. But Karen Ballard, director of practice
and government affairs with the New York Nurses Association
and the union’s point person on smallpox, says these risk
assessments require some reading between the lines.
the statistics that you’ve read about the side effects and
adverse effects of using the vaccine are based on the experiences
of the ’60s and ’70s,” says Ballard. “Look at the footnotes
on that data; that information is over 40 years old. The
population of the United States is very different. So when
they talk about the rates of adverse effects and side effects,
no one can guarantee that.”
Ballard refers to statistics from the article “Complications
of smallpox vaccinations, 1968” from The New England
Journal of Medicine. Not only does the 34-year-old study—quoted
by every journalist, politician and medical professional—represent
the last risk assessment for mass smallpox vaccinations,
it was published at a time when inoculations were still
routine. Ballard and a host of others say that the data
is seriously outdated and the president’s program is being
pursued without adequate information—that it’s a test case
call this the demonstration phase in my own head,” Ballard
says. “This is the first phase where we’re going to use
the vaccine and we’re going to see what happens.”
The vaccine is introduced to the human body through a number
of pricks to the arm with a bifurcated, or two-pronged,
needle. Since the smallpox vaccine is itself a live virus,
serious and potentially fatal side effects can result. As
the vaccination wound heals, it must be cared for properly
or there is a risk that others could become infected with
vaccinia. Known side effects from the vaccine include encephalitis
(swelling of the brain) and severe flulike symptoms.
The CDC, which is administering the president’s program,
acknowledges that the U.S. population is much different
than it was 30 years ago and has warned a number of people
not to participate.
According to the CDC, those most likely to have serious
side effects from the vaccine include people who have had,
even once, skin conditions like eczema, and people with
weakened immune systems—people who are HIV positive or are
receiving treatment for cancer or have received an organ
transplant. Children and pregnant women also could have
side effects from the vaccine. The CDC has cautioned these
people against participating in the program, but it has
not offered projections of deaths and illnesses that the
vaccine might cause today.
says her union has not yet taken a position on the issue,
but the prospect of endorsing the vaccination program for
her union’s 34,000 nurses with so many unanswered questions
It is still uncertain how those who become sick because
of the vaccine will be compensated. Vaccinated workers are
to remain on the job, and Ballard says that many of her
nurses are concerned about infecting patients. She says
that workers in New York will receive compensation if they
are still sick and missing work seven days after receiving
the vaccine. But she says that gesture may be too little
you’re sick more than seven days after the shot, then you’ve
had an adverse effect, not a normal side effect,” Ballard
Despite all of these concerns, Ballard knows that a number
of nurses will volunteer for the smallpox vaccine, seeing
it as their duty. But she questions the president’s proposal
on the number of health care workers the country needs to
vaccinate in order to deal with a smallpox attack.
don’t understand phase two [vaccinating 500,000 health care
workers],” Ballard says. “I can most certainly understand
the country wanting a core population of health care workers
who could move out and vaccinate other health care workers
if there were a need. There is no doubt that that is a public
things said,” she continues, “smallpox is a virulent, deadly
disease. If that were to become a biological weapon used
against any population, it would be deadly. It is a rock
and a hard place.”
Peter Jahrling has seen his share of deadly, infectious
Jahrling is the principal scientific advisor for the U.S.
Army Medical Research Institute of Infectious Diseases in
Fort Detrick, Md., the nation’s principal biodefense laboratory.
Over the past few decades, Jahrling has spent time in the
labs and in the field exploring and curing some of the most
deadly diseases our country has seen. This has been no small
In 1989, Jahrling discovered, captured and named the strain
of the Ebola virus that broke out in Reston, Va. When a
number of media outlets and the office of Sen. Tom Daschle
(D-S.D.) were mailed envelopes containing anthrax in October
2001, Jahrling was called in to identify the bacterium.
He and his colleagues created and perfected Cipro, the anthrax
vaccine. With all of his experience working with a number
of deadly, infectious diseases, Jahrling maintains that
smallpox is the greatest biological threat facing the United
is an inherently nasty disease,” Jahrling says, “which produces
30 percent mortality and nearly 100 percent morbidity in
populations exposed to the naturally transmitted infection.
. . . And of course all morbidity and mortality data from
the global eradication era pertained to partially immune
populations, either immunized or recovered from authentic
disease. Everything would be much worse in a . . . virgin
Smallpox is extremely contagious, and as few as 10 smallpox
particles can spread it. The disease is airborne, and an
infected person exudes smallpox particles when opening his
mouth to speak. It would take three million smallpox particles
touching end-to-end to span the period at the end of this
When someone contracts smallpox, the disease masks itself,
and the infected shows flulike symptoms while the virus
incubates. The disease is contagious during incubation.
Smallpox sufferers see a sharp spike in temperature and
general discomfort at the onset of the disease. Soon thereafter,
little red spots begin to appear all over the body. The
spots begin to rise and form pea-sized blisters, called
pustules. The pustules swell and firm with a colored puss.
The skin begins to resemble bubble-packing wrap with less
symmetry. The pustules are prying the layers of skin apart.
Scientists are unsure of exactly how smallpox kills its
victims, but death is often brought on by a breathing or
cardiac arrest, or bleeding. Upon infection, the probability
of death is relatively easy to gauge. If the individual
pustules merge into each other across the skin, smallpox
is said to have split the whole skin—encasing the body in
a layer of puss—and the victim will most certainly die,
usually from an arrest. If the pustules stay separate, they
may begin to scab over, and the victim will live with scarring.
The most gruesome variety of smallpox is referred to as
black, or hemorrhagic, pox. With black pox, dark spots of
unclotted blood form under the skin as the disease deteriorates
the linings of the throat, stomach, intestines, vagina,
anus and other interior membranes. The remains eventually
pass through the body’s orifices, and the person bleeds
to death. Black pox is nearly 100-percent fatal.
The effects of the disease can be blunted through vaccination—even
prevented if received within four days of exposure. Until
the signs of an outbreak are detected, though, the disease
has time to spread, which it easily could in a society where
a the majority of medical professionals have never seen
an actual smallpox patient. Jahrling says it would take
only one undiagnosed case of smallpox today to create a
makes smallpox scarier than anthrax is that it is a contagion,”
Jahrling says. “Each case begets at least three more, via
person-to-person contact. Couple that with the increased
mobility in industrialized nations, and epidemic spread
is virtually ensured.”
For the last few years, it has been Jahrling’s job to work
with smallpox and to find better treatments post-exposure,
including, possibly, a cure for the disease. Currently he
and a group of scientists are working on a number of antiviral
drugs, like cidofovir (currently used to treat HIV patients),
and other, less-dangerous smallpox vaccines.
is unrealistic that we will have a ‘cure,’” Jahrling said.
“But there is a 10-day incubation period for smallpox during
which time an antiviral drug could supplement the [benefits]
of post-exposure vaccination. You can’t just write off the
folks who can’t receive vaccine or those who aren’t reached
within four days of exposure.”
Jahrling is also concerned about the previously mentioned
intelligence about leaked smallpox stocks. In fact, Jahrling,
having spent time at dilapidated Soviet laboratories and
having spoken with the Russian scientists who worked in
them, has contributed to these reports.
One might say, cynically, that Jahrling’s opinion derives
from his livelihood, as his work depends on the threat of
a smallpox attack. But Jahrling’s concerns about the dangers
of a smallpox outbreak and unaccounted-for smallpox stocks
are widely shared. In reality, his voice is but one in a
Yet, critics of the Bush administration’s mass-vaccination
program are quick to point out that the one voice that should
be ringing clearest in that chorus—President Bush’s—has
thus far been filled with little more than empty notes.
The danger of smallpox, the disease—should the U.S. population
face an actual outbreak—is inarguable. The threat of smallpox,
the weapon—being unleashed on the U.S. population—is still
don’t know that [the Bush administration] has made [the
case for smallpox vaccinations] sufficiently well,” said
Christopher Hellman, senior analyst for the military watchdog
Center for Defense Information. “I think that is one of
the reasons why the program is voluntary. I think [the low
volunteer turnout] speaks volumes. The people have, in their
own minds, done the risk assessments and decided that getting
the vaccine is not necessary.”
As of Feb. 11, the CDC reported that 1,043 people had been
vaccinated in 19 states nationwide, though it had shipped
250,000 doses of the vaccine to 41 states. On Feb. 7, The
New York Times reported that state of Texas pressed
its 550 acute-care hospitals to decide whether or not they
would comply with the president’s vaccination program, and
175 refused to participate.
Jean McGrath teaches at the Albany College of Pharmacy and
is a member Albany’s Healthcare Emergency Operations Coordinating
Committee. The group initially was formed in 1997 to coordinate
efforts for local officials to prepare for Y2K. Now the
group’s focus is smallpox preparedness.
Locally, McGrath says, the smallpox vaccination efforts
have generally mirrored the efforts nationally. Preparations
to inoculate the inoculators have begun slowly and discreetly.
Volunteers have been few at local hospitals. Two area hospitals,
Schenectady’s Ellis and Troy’s St. Mary’s, have yet to decide
whether they will participate in the vaccination program.
McGrath says the vaccination program is in preliminary stages,
but acknowledges that turnout, so far, is less than expected.
She said the turnout is linked to hospitals’ and health
care workers’ desire for answers to the many unanswered
questions surrounding the president’s vaccination program.
hospitals and health care workers going to be personally
responsible, or is somebody else going to take care of that?”
ponders McGrath. “Is any of this really covered in the Homeland
Security Act? It is basically a new document, and nobody
knows the answers to that yet.”
McGrath says local hospitals would like to vaccinate roughly
100 people each to prepare for a smallpox event, but she
said achieving that goal without a smallpox event
is highly unlikely.
The Bush administration has done little to answer the questions
posed by hospital officials and health care workers. Nor
has the imminence of a smallpox threat been outlined, which
would show a need for 10 million vaccinated first responders.
The buck has been passed to the states and, at least in
New York, they are saying very little. Federal officials
have gone back to spinning the National Security Advisory
color wheel (High Risk Orange this week) and touting the
domestic security benefits of duct tape and plastic sheeting.
None of this is drawing more volunteers to the front line
of a speculative battle against one of biology’s deadliest
that there is no risk at this point from the disease,” says
Ballard, “people just feel a little tentative, and they’re
waiting to see what happens when other people are vaccinated.”