Politics & Policy

Smallpox Strategy

Waiting won't work.

As we move deeper into Iraq and with al Qaeda and other Islamic terrorist groups threatening new attacks against the U.S., it is time to embark on a mass smallpox-vaccination program for the general public.

In late December President Bush approved a much wider vaccination program against smallpox than that recommended by many public-health experts. The decision was not an easy one considering the serious side effects the vaccine can trigger. But the president’s job is to make difficult decisions; anyone can make easy decisions.

Smallpox is a highly lethal and highly contagious disease for which there is no cure: Thirty percent of those infected die, and many of the rest are horribly disfigured. The only defense against it is vaccination.

The enemy’s objective, stated repeatedly in their literature and in numerous communiqués, is to destroy America and kill as many Americans as possible. U.S. troops found al Qaeda manuals on chemical and biological warfare in Afghanistan, together with evidence of experimentation on animals. The anthrax attacks of the fall of 2001 showed that terrorists, domestic or foreign, have the capability to mount biological attacks in the U.S.; the unthinkable has become reality.

In light of these facts, mass vaccination of the American population against smallpox would seem to be the prudent course of action. Many public-health officials, however, have counseled against taking just that step.

The main objection raised by health officials is concern with the number of possible deaths and illnesses in the wake of mass vaccination, which, according to different estimates, is in the range of approximately one to two deaths and several dozen to a hundred serious illnesses per million.

The health experts’ solution is post-attack vaccination, as the vaccine is also effective if administered within a few days after the subject has been infected and before the onset of symptoms. The system advocated is called “ring containment,” whereby local outbreaks of smallpox are ringed by circles of quickly vaccinated people.

As a strategy, however, ring containment is fatally flawed. The logistics of ring vaccination in an emergency are nightmarish. The “Dark Winter” exercise of 2001, simulating a multi-focal smallpox attack, depicted a health system overwhelmed in less than a week, with tens of thousands dead and with the outbreak still uncontained.

The strategic thinking behind preemptive mass vaccination is to minimize uncertainty, not maximize it. The objective is to control circumstances, not be controlled by them. That same kind of thinking is behind the Bush administration’s new strategy of preemption, designed to prevent the acquisition of weapons of mass destruction by rogue states.

Strategy is the device through which we control our fate despite adverse circumstances and conditions of uncertainty.

Mass vaccination may be an imperfect policy with some risks — what policy isn’t? — but it is a highly effective one, as it minimizes uncertainty and protects the public from one of the enemy’s most potent weapons.

The conundrum of the mass-vaccination skeptics is how to deal with risk, a subject that many Americans obsess over. They want information on the likelihood of a smallpox attack, and whether there is a “specific threat.” Perfect information is demanded in order to make a perfect decision. And there lies the fatal flaw in their thinking.

The likelihood of an attack is an assessment based on partial and sometimes unreliable information. September 11 happened despite being “highly unlikely” at the time. That is the nature of surprises — they surprise you.

What is determinable, though, is that, should an attack occur now, tens of thousands of people could die and millions could be scarred for life. We should assume the worst and prepare accordingly. As the television ad says: Sometimes the biggest risk is not taking one.

The issue of potential lawsuits brought against the government and the vaccine manufacturers by sufferers of side effects is also raised as a reason not to vaccinate. Incredibly, lawyers frighten the bureaucrats more than bio-terrorists, lawsuits being a clear and present danger. We are more afraid of attorneys with files than of terrorists with vials.

The absence of smallpox resistance is a weak point that could lead the enemy to our center of gravity: the health of the American public. A sound defensive strategy is to protect one’s center of gravity. Our strategy should be based on an evaluation of the enemies’ objectives and capabilities — not on uncertain assessments of their intentions. Maintaining a willful posture of vulnerability is not a strategy — it’s the lack of one.

Jonathan Friedman is director of the Washington office of Demoman International, a homeland-security consulting firm.


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