EDITORIAL

The Huge Smallpox Question

TEMPTING though it would be to imagine otherwise, there is no risk-free way to protect the American population from an outbreak of smallpox. This deadly, disfiguring disease was eradicated in its natural form in 1980 but still exists in scientific laboratories in Russia and the United States. The possibility that it could also exist in other, unknown countries, in unknown quantities, has, over the past year, prompted the Bush administration to order and stockpile large quantities of smallpox vaccine -- theoretically enough to inoculate every American in case of an emergency. Public health officials have also started training nurses and others (Montgomery County began last week) in the emergency use and distribution of the vaccine.

But however carefully prepared, no emergency program, designed for use solely in the crucial days after a bioterrorism attack, can ever be guaranteed to be completely effective. Current plans call for the use of high schools as emergency vaccination centers, the construction of intricate data systems, the use of the National Guard to keep order. But in the event of an actual attack, it would be hard to prevent the public from panicking, and the system from disintegrating into chaos.

The alternative is a mass program of advance inoculation -- a strategy that carries different kinds of risks and is far from the panacea some imagine. The smallpox vaccine, out of circulation for 30 years, is not as safe as some of the other vaccines now in use. Some 15 people out of a million inoculated would become seriously ill, and one or two of them would die. Worse, those who have been inoculated can inadvertently infect others, particularly those with skin diseases or HIV-AIDS. Because we have little recent experience with the vaccine, we don't really know how many such people would be affected. For that reason, the decision to be vaccinated cannot simply be left up to individual choice, as some have advocated. This is a public health issue, not a question of personal freedom.

In the past, decisions about vaccination were easier to make because smallpox itself was so terrifying. Nowadays, however, we are weighing the certainty of deaths and illness from mass inoculation against the uncertainty of deaths and illness from a possible terrorist attack. Everyone will have different priorities in this debate, and perhaps it is not surprising that those primarily concerned with national security are pushing for a higher rate of inoculation and those primarily concerned with the current health of the general public advocate greater caution. It is also true that public expectations are different than they used to be. Most Americans now assume that anything the government recommends is safe -- and will want compensation if it is not.