A call to bare arms vs. smallpox
Seth L. Haber, MD
This may be a good time for physicians, nurses, and other
care workers who do not want to be vaccinated against
smallpox to examine and prioritize their personal and professional
obligations to the immunity of the herd.
With a disease that spreads as easily and rapidly as smallpox, our
safety (individual, community, national, and international) is a
function of our own immunity and that of everyone else—the
herd. We are only as safe as our neighbors. That is why health care
workers, in my view, should set an example by stepping forward now
to be vaccinated and why other groups should do so as they become
Let’s go back about 40 years. Smallpox vaccination was generally
required and universal; you couldn’t enter public school without
it. School nurses lined up the children, each child was vaccinated,
the inoculation site was casually covered with gauze, and the children
were sent on their way. The risk of complications or death from
the vaccination did not constitute an excuse not to be vaccinated.
Even those of us who can find the vaccination scar are no longer
immune. It lasts only a decade or two, and we haven’t vaccinated
for some 30 years in this country. D.A. Henderson’s success
25 years ago in eliminating variola ended vaccination and made us
all susceptible, and thereby qualifies smallpox as a doomsday bioweapon.
Smallpox has been used previously in biological warfare: Scab material
was spread on the blankets that conquerors of the new world gave
to the native Indians, and, in other periods, the bodies of those
who died of smallpox were catapulted over the walls of towns under
We have been warned that vaccination, under the currently proposed
program, will produce 50 life-threatening complications and one
or two deaths per million people, based on data extrapolated from
other countries. But the new lower-dose vaccinations may lessen
those rates. Whatever the herd rate, complications will be much
higher in patients who are immunocompromised and lower in those
How communicable is smallpox? The natural strain is second only
to influenza and measles in the ease, rapidity, and surety of its
spread. Infection takes only one inhaled particle and generally
can be spread to 10 to 20 people in the 10 to 14 days before it
can be diagnosed. Mortality from natural strains is generally up
to 50 percent, but it approaches 100 percent in some virulent forms.
Smallpox has killed more people than any other epidemic disease.
I specify “natural strains” because the Soviet Union’s
bioweaponeers are reported to have modified the DNA of natural strains
to increase the virus’ infectivity and virulence. They have
also genetically engineered recombinant smallpox chimeras, with
viruses causing Venezuelan equine encephalitis, as well as Marburg,
Ebola, and other hemorrhagic fevers. Ebolapox could produce “blackpox,”
which should be 100 percent fatal. They may also have developed
strains against which vaccination with natural strains of vaccinia
Physicians, nurses, technologists, and other health care workers
who have declined vaccination justify their positions with one or
more of the following arguments:
- The morbidity
and mortality from the vaccination are unacceptable.
- There may
be secondary spread of vaccinia to immunocompromised persons.
- There may
be secondary spread of vaccinia to family members.
Bush was using the program to spread fear, thereby deceptively
mobilizing the country for war with Iraq.
lack the capacity to smuggle and release smallpox in our country.
never catch smallpox, if I’m careful.
have plenty of time for post-event vaccination.
really chemical and nuclear attack that we have to fear.
- The program’s
costs are significant and would probably come out of other worthy
and significance of the first three points are largely unknown.
It’s difficult to compare unsupported mortality and morbidity
extrapolations with the unknown probability of a bioterrorist attack.
Regarding unacceptable morbidity and mortality: At what probability
of occurrence does who decide that it is worth risking some 300
deaths (at one per million) to prevent about 120 million possible
deaths (at 40 percent mortality)? Like it or not, how to respond
to that ratio of about 1:400,000 is the heart of the problem—all
else is persiflage. Whether anyone will listen to that decisionmaker,
and whether those who listen will have time to act, are also important
How was it determined that holding the entire population hostage
to the needs of the immunocompromised is a higher morality? Is it
more ethical to risk the lives of the vast majority in favor of
the needs of a relative few, the length and quality of whose lives
may be diminished by their primary diseases? We must, of course,
provide for their medical needs, including isolation, but the quality
of their lives is not enhanced by subjecting the majority to the
other edge of the sword.
The possibility of spread to family members is debatable and might
be as much a benefit as it is a hazard—similar to, for example,
the secondary spread of live polio vaccine, chickenpox (varicella)
parties to protect against future herpes zoster, and German measles
(rubella) parties to help immunize against measles (rubeola).
That President Bush may have been intentionally spreading fear is
political dogma, discussion of which will generate far more heat
Regarding bioterrorists’ capacity to release smallpox: Effecting
a cataclysmic spread of smallpox is low tech, certainly less than
that which is required to commandeer three huge jets and fly two
of them into the “sweet spots” of New York’s twin
towers. In the 1990s, Russian bioweaponeers learned to grow smallpox
virus in large (>630 liters) pharmaceutical tanks, enabling them
to produce tons of it in dozens of facilities. When the USSR broke
up, the biological warfare programs closed down. Hundreds of then-unemployed
scientists took their knowledge of the methods and techniques used
by the Russian programs to new jobs in Iraq, Korea, and other countries
that are enemies of the U.S. The scientists as they left Russia
could easily have carried master seed strains of viruses in one
of their jacket pockets, if not a potentially end-of-civilization
supply in innocuous-looking bottles.
The Russian scientists were able to produce liquid smallpox by the
gallons, subsequently stored in lyophilized, powder, and liquid
forms. Twenty tons of bioweaponized liquid smallpox were stored
on Russian military bases, ready to be loaded onto warheads. The
dry powders are the most powerful bioweapons, with particles less
than five micra in diameter, designed to lodge in the lungs. The
powder is frighteningly self-dispersing, and the liquids are easily
aerosolized. Most of the hundreds of tons of infectious smallpox
material is unaccounted for—it simply disappeared. It can
be smuggled into this country more easily than out of Russia, probably
in the same innocuous, concealable containers.
Regarding our personal immunity: Despite Herculean efforts by health
officers and public health departments to mobilize, organize, and
educate first-line physicians, most clinicians have no idea what
even classical smallpox looks, feels, or smells like, and it would
be a long time before we would diagnose it. Henderson, who has seen
more cases than anyone and who literally wrote the book, says smallpox
takes forms even he can’t diagnose. Does smallpox belong in
the differential diagnosis of every case
of cough, sore throat, chills and fever, or exanthema? Even if you
diagnose the first case you see, by then everyone in your office,
clinic, or emergency room, including you, your colleagues, and assistants,
will have been exposed.
In the 10 days to two weeks after exposure, before smallpox can
be diagnosed, each person can infect 10 to 20 others. That’s
the first wave. Subsequent waves, on a two-week cycle, increase
by a factor of about 20. Henderson said about 100 million doses
of vaccine would be needed to stop an epidemic in the U.S. if it
began with only 100 cases.
If only 10,000 people are infected in a large city during a bioterrorist
fly-over, those victims will have infected 100,000 to 200,000 others
by the time it is diagnosed. That’s the second wave, and it
will surely involve other cities
by then. Thus, we will probably be well into the third wave, of
1 million to 4 million, all over the world before we can even begin
a program of vaccination. Of course, we’ll be diagnosing it
in unvaccinated health care providers by then.
Why not vaccinate post-event? Bioterrorists can spread smallpox
by releasing the agent while flying over major American cities in
small rented planes. Or they can release a small container of powder
into the air intake system of a major international airport. It
doesn’t even have to be on U.S. soil. Essentially everybody
in the airport would be infected and become an innocent but undetectable
smuggler. If the bioterrorists said nothing, the infected persons
would each fly off to their respective destinations, innocently
infecting 10 to 20 others in the next 10 to 14 days, in foci throughout
the world. Clearly, too many cases and too widespread to be contained
by Henderson’s ring of vaccination. Remember, a single person
infected with smallpox used to be a global medical emergency. Imagine
the riots if the terrorists made a post-event announcement. Who
would exercise what authority to command who to close O’Hare
When a case of smallpox popped up in Yugoslavia in 1972, containing
it took the resources and commitment of its authoritarian government.
It mobilized the army, exercised full emergency powers, and closed
off the country, so that the World Health Organization could administer
18 million doses in 10 days, before the waves of cases stopped.
It took a military crackdown and vaccination for every citizen.
Contrast that with our commitment to individual rights, personal
freedom, and confidentiality, our desire to debate everything, our
demand for at least a court hearing, and the refusal of some hospitals,
as well as unconvinced physicians and other health care workers,
to participate. Oh yes, we’ll have plenty of time.
With the downsizing of the pools of people who would have constituted
emergency response teams, the surge capacity begins to approach
zero. How, then, would we vaccinate 250 million Americans in 10
days? And just who is “we”? Where are the frozen ampoules
of vaccinia, and how will they be distributed to the vaccination
centers? If one death and 50 serious complications per million people
vaccinated is worrisome, consider the morbidity and mortality that
could result from panicked mobs rioting to be vaccinated. How long
will the exhausted members of those first response teams, who are
vital to the program, be willing and able to play their designated
roles? And how will we protect the immunocompromised?
How should or will we respond to other nations claiming entitlement
to a humanitarian share of our supplies of vaccine? Would our neighbors,
like Canada and Mexico, launch a first strike in our border states
to get at supplies for their nationals?
Although chemical and nuclear weapons of mass destruction are horrendous,
they affect only the area in which they are released. Biological
weapons, on the other hand, are communicable and self-perpetuating.
They are the gift that keeps on giving. The valid fear of other
weapons of mass destruction does not justify refusing to prepare
for those we can.
Finally, concern about the program’s cost is valid. It will
probably be even greater than the highest estimates and will come
largely out of other health programs. Yes, it’s a zero sum
game. It’s a matter of priorities, who sets them, and whether
In my view, all health care workers who would be exposed early while
caring for patients should be vaccinated while they can. They should
give thanks to the U.S. government for initiating the program, thanks
to the pharmaceutical companies for being able to produce the vaccine,
thanks that they are among the first to qualify for it, and thanks
to any and all if I am totally wrong.
is emeritus chief of the Department of Pathology, Kaiser Permanente
Medical Center, Santa Clara, Calif., and clinical professor of pathology
at Stanford University School of Medicine. Dr. Haber offers as additional
reading three articles from The New Yorker that he says “will
ruin your day and interfere with your sleep until you repress them.”
Written by Richard Preston, they are as follows: “The
Bioweaponeers,” March 9, 1998, http://cryptome.org/bioweap.htm;
“The Demon in the Freezer,” July 12, 1999, http://cryptome.org/smallpox-wmd.htm.
“Gluttons for punishment,” he adds, might enjoy these
books: Preston’s The Demon in the Freezer: A True Story,
Random House; Biohazard:The Chilling True Story of the Largest
Covert Biological Weapons Program in the World, by Ken Alibek
(who directed the Russian bioweapons division before defecting to
the U.S.), Dell Publishing; and The Coming Plague, by Laurie
Garrett, Penguin Books.