500,000 Is Not Enough

July 13, 2002 • Commentary

The new plan to inject 500,000 health and safety workers with the smallpox vaccine is a good first step in a preventive war against bioterrorism — but it’s not enough. There are some 290 million Americans and the vaccine stockpile will be more than 450 million doses by the end of this year. In this great country, Americans should be allowed to choose for themselves to take the smallpox vaccine or not.

Americans are not children in need of a government nanny to take care of them from cradle to grave. And in this case, it’s worth noting that prior to the eradication of smallpox in the 1970s, all U.S. children were vaccinated to prevent the spread of the disease. That was a prudent policy. Giving Americans the freedom to choose the vaccine today is another prudent policy.

The first responsibility of the federal government is to protect its citizenry and the most effective defense (and deterrent) against a smallpox attack is a well‐​vaccinated population. A recent study by experts from Yale University and the Massachusetts Institute of Technology shows that vaccination of the U.S. population (even if only a fraction was vaccinated) before an attack worked best to reduce fatalities and the number of days to contain the outbreak when compared to all post‐​attack responses (including both ring containment and mass vaccination).

The federal government needs to shed it’s paternalistic “father knows best” attitude about the smallpox vaccine. Even President Bush said, “I haven’t made any decisions as to who is going to be vaccinated or not.” With all due respect to the president, it’s not his decision. In a free society, it’s a decision that individuals should make for themselves.

Because there are known risks with the smallpox vaccination (in particular for those with weakened immune systems), individuals should be allowed to make a voluntary, informed decision (in consultation with a doctor) to understand, manage, and mitigate those risks. In all likelihood, those who are most at risk to the vaccine would make the decision to opt out and not be vaccinated, thereby greatly reducing the number of potential deaths and side effects.

And it’s important that individuals be allowed to make their decisions before a potential attack. If vaccination is an option only after a crisis erupts, the public health infrastructure and health workers are likely to be overwhelmed. As a result, people will either be forced to be vaccinated (regardless of the risk or against their own personal wishes) or be faced with the stark decision of having to accept the risks associated with the vaccine or to be exposed to smallpox.

Moreover, recent reports that three‐​quarters of HIV‐​positive gay men are unaware that they have the virus underscores the importance of having the time to conduct tests beforehand to determine whether an individual might be at risk to the smallpox vaccine. Such testing is not likely to occur in the inevitable post‐​attack chaos when government authorities are quarantining and mass vaccinating millions of people.

Because the smallpox virus is a live vaccinia virus there are legitimate concerns that people who are vaccinated may unintentionally transmit the virus to unvaccinated individuals who are at risk to the vaccine (such instances are rare and generally the result of household contact or children‐​to‐​children contact). These concerns can be addressed by the use of a semi‐​permeable membrane dressing that prevents viral shedding. A self‐​quarantine is another option, and a decision could be made not to vaccinate children under a certain age (e.g., 5 years old or 9 years old). Again, these measures will be easier to implement and more effective before an actual attack rather than after.

The bottom line is that Americans are smart enough to decide for themselves about the smallpox vaccine. But the government’s decision to vaccinate only first‐​responders assumes otherwise. Vaccinating first‐​responders certainly makes sense, but it’s the American public — not just the first‐​responders — who are at risk to a potential smallpox bioterrorist attack. Given that the federal government couldn’t predict September 11 and didn’t immediately understand the subsequent anthrax attack, why should the decision about smallpox vaccine be left totally in their hands? The federal government needs to live up to its responsibility to protect Americans beforehand rather than simply responding after the fact by making the smallpox vaccine widely available for all to choose … sooner rather than later.

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