Jewish World Review Feb. 4, 2003 / 2 Adar I, 5763
Jonathan Rauch
Stop whining, America, and get serious about Smallpox
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Having lived through the 20th century, Americans know better
than to shrug off the threats of ruthless, desperate, and
possibly mad dictatorships ("Oh, that's just the way Hitler
talks"). Last month, North Korea warned of turning America
"into a sea of fire." At the moment, North Korea may have
at most two nuclear weapons, with no reliable way to deliver
them across the Pacific. How, then, might this little asylum
case bring mass death, destruction, and panic to American
shores?
Smallpox constitutes one of America's two most glaring strategic
vulnerabilities, rivaled only by loose nukes. No one knows
who, apart from the Russians, may have smallpox on hand,
but North Korea is a leading candidate. The disease is virulently
contagious, and it kills about 30 percent of the people
who come down with it and disfigures or blinds many of the
rest. And North Korea threatens to annihilate America. And
Saddam Hussein is capable of who knows what. And America's
vulnerability practically begs for an attack or a panic-inspiring
threat. All of this we know.
On Jan. 24, Connecticut became the first state to begin
immunizing some health care workers against smallpox. The
Bush administration hopes to inoculate as many as 500,000
health workers in the next few weeks, and several million
more "first responders" (health and emergency personnel)
in the months after that. This is good.
But the effort began not with a bang but a snivel. In Connecticut,
all of four people showed up to be inoculated. "A growing
number of hospitals and medical groups decided not to participate
-- at least for now," reports The Washington Post. Alabama
initially planned to inoculate 12,000 people, but the actual
figure looks to be more like 2,000 to 5,000, according to
The Post, which adds that Ohio, Colorado, North Carolina
and other states "are scaling down their programs." The
New York Daily News reports that "some 80 hospitals in 22
states are balking at inoculating their staffs."
Meanwhile, nurses' organizations in California, Rhode Island
and Massachusetts advised their members not to volunteer
for inoculation. Health care workers' unions are doing the
same. The American Nurses Association demanded that the
campaign be delayed "until key concerns are addressed,"
among them "the right of coverage of medical costs associated
with receiving the vaccine," "compensation for lost time
at work due to adverse effects of the vaccination program,"
and "protection from job discrimination or retaliation for
refusing to be vaccinated."
If health care workers reject vaccination, the effect may
reverberate through the general population. The voluntary
vaccination of, say, 60 percent of the American public could
help reduce the toll of a smallpox attack by more than 90
percent, as recent simulations by the Brookings Institution's
Center on Social and Economic Dynamics vividly showed. Two
polls in December found, respectively, 59 percent and 46
percent of the public willing to take the vaccine even when
apprised by the pollsters of "some risks involved" (59 percent)
or "serious side effects or death in a small number of cases"
(46 percent -- still a plurality). The public's willingness
to volunteer for inoculation represents a precious civil-defense
asset; health care workers' well-publicized skittishness
risks squandering that capital. After all, if the vaccine
is too dangerous for my doctor or nurse, it surely must
be too dangerous for me.
Are the foot-draggers right? Consider their arguments:
- "The vaccine poses real health risks, but the smallpox
threat is entirely conjectural."_ True, there is no proven
smallpox threat. Chances are we won't know until the virus
is actually released. The issue, however, is not public
health but national security. The goal is not to make people
healthier than they would otherwise be, which is what public
health measures are usually for; it is to make the country
less vulnerable to attack and -- every bit as important
-- intimidation. America's strategic vulnerability is clear
and present, even if the virus is not. Security is worth
something, even at the cost of a few lives.
It's understandable that health workers should think and
talk like health workers rather than security strategists.
But the Bush administration should think and talk about
national defense. Why isn't it making the case, prominently
and assertively?
- "But there's no compensation program for people who are
injured by the vaccine or who miss days of work."_ True
enough, and the Bush administration's failure to create
a program is a baffling lacuna. But this does not end the
discussion.
To begin with, many people who suffer adverse reactions
to the vaccine will be covered by health insurance. Some
will qualify for workers' compensation. Private charities
can help, too. One way and another, not many people hurt
by a smallpox inoculation will die on steam grates. The
government should set up a formal program, and it may yet
do so (interest is keen on Capitol Hill). But North Korea
rumbles _now_. If, as the American Nurses Association suggests,
vaccinations are delayed until every eventuality is provided
for, the wait will be long. Possibly too long.
That is the minor point. Here is the major one. Didn't someone
once say, in the face of an earlier threat, "Ask not what
your country can do for you; ask what you can do for your
country"? Didn't many people complain that President Bush
failed to ask Americans to do anything more serious about
terrorism than go shopping? Well, here is a chance for individual
Americans to step up and make a real difference. Some of
them will miss work, yes. But have we really reached a point
where Americans won't donate a few days of their working
lives to help protect their country against a leading terrorist
threat?
A few people, of course, will have serious health complications
rather than just missed workdays. That is a problem. But
the risk of a potentially life-threatening reaction to the
smallpox vaccine is between 14 and 52 per million inoculations,
according to the Department of Health and Human Services,
and the odds of death are one to two per million. By comparison,
the chance of dying behind the wheel of a car is about 24
per million drivers per year. In other words, the fatality
risk you would assume by taking the smallpox vaccine is
about a 10th the risk you assume by driving around, and
the reason for being vaccinated seems somewhat more compelling
than, say, the need for a Slurpee.
- "The real problem is that nonvolunteers can also be infected
by the vaccine virus and can be crippled or killed."_ This
is the reservation that thoughtful public health officials
voice most often. As The Post reports, "Physicians said
their main concern is for patients and family members who
might inadvertently be infected by the live-virus vaccine."
The site of the smallpox inoculation on the body can shed
vaccinia virus, which, if it infects someone who has a compromised
immune system -- say, an HIV or cancer patient -- can kill
in a horrible way. In an interview, John Neff, a pediatrician
and infectious-disease specialist at the University of Washington
School of Medicine, told me, "If I were to go out and get
vaccinated for myself, and I inadvertently infect my spouse
or someone I didn't even know had an immune problem, and
that person died, I've done a terrible thing." Moreover,
even one such case in the national headlines could cause
a backlash against not only smallpox vaccination but against
vaccines generally.
It is proper to be concerned about this problem. But it
is not proper to be paralyzed by it. Working from data that
Neff and three of his colleagues recently published in the
Journal of the American Medical Association, I figure the
odds of dying from "contact vaccinia," as it's called, at
two to four per 10 million inoculations. In 2001, by way
of comparison, every 10 million licensed drivers caused
the deaths of about 300 pedestrians and other nonriders
-- people who had not voluntarily assumed the risk of getting
into an automobile.
Notice, please, that driving a car is on the order of 100
times more likely to kill a bystander than is getting a
smallpox inoculation. Yet we do not prohibit driving. Nor
do we even discourage it. Nor do we run a national compensation
program for pedestrians injured by automobiles. Rather,
we recognize that a sensible society puts up with certain
small risks in the pursuit of larger goals.
So the people who are foot-dragging on smallpox vaccination
are really people who are asking this: "Should Americans
be expected to assume a mild inconvenience or a minuscule
risk in order to help secure their nation against a fearsome
attack?" A country, or a government, that fails to answer
that question very clearly in the affirmative is either
neurotic about risk or unserious about terrorism. Or both.
JWR contributor Jonathan Rauch is a senior writer and columnist for National Journal. Comment by clicking here.
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© 2002, The Atlantic Monthly, from where this is reprinted
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