about Epidemiology & the department

Epidemiology academic information

Epidemiology faculty

Epidemilogy resources

sites of interest to Epidemiology professionals

Last Updated

19 Dec 2002

Source: Time, December 23, 2002.


Smallpox Shots: Make Them Mandatory

When it comes to epidemic diseases, you don't get to decide. The state decides


The eradication of smallpox was one of humanity's great success stories. After thousands of years of suffering at the hands of the virus, the human race gathered all its wit and cunning and conquered the scourge, eradicating it forever. Well, forever lasted less than 25 years. It does not bode well for the future of our species that it took but a blink of the eye for one of history's worst killers to make a comeback not on its own, mind you, but brought back by humans to kill again.

During the age of innocence the '90s, during which it seemed history had ended the big debate was whether the two remaining known stocks of smallpox in the world, one in Russia and the other in the U.S., should be destroyed. It seemed like a wonderful idea, except that no one could be absolutely sure that some smallpox stores had not fallen into other hands. In fact, we now think Iraq is working on weaponizing smallpox, and perhaps North Korea and others too.

The danger is greater now than ever first, and ironically, because of our very success in eradicating it in the past. People today have almost no experience with, and therefore no immunity to, the virus. We are nearly as virgin a population as the Native Americans who were wiped out by the various deadly pathogens brought over by Europeans. Not content with that potential for mass murder, however, today's bad guys are reportedly trying to genetically manipulate the virus to make it even deadlier and more resistant to treatment. Who knows what monstrosities the monsters are brewing in their secret laboratories.

What to do? We have enough vaccine on hand, some diluted but still effective, to vaccinate everyone in the U.S., with more full-strength versions to come. President Bush has just announced that his Administration will take the concentric-circle approach: mandatory inoculations for certain soldiers, voluntary inoculations for medical and emergency workers, and then inoculations available to, but discouraged for, everybody else.

It sounds good, but it is not quite right. If smallpox were a threat just to individuals, then it could be left up to individuals to decide whether or not they want to protect themselves. When it comes to epidemic diseases, however, we don't leave it up to individuals to decide. The state decides.

Forget about smallpox. This happens every day with childhood diseases. No child can go to school unless he's been immunized. Parents have no choice. Think of it: we force parents to inject healthy children with organisms some living, some dead that in a small number of cases will cripple or kill the child. It is an extraordinary violation of the privacy and bodily integrity of the little citizen. Yet it is routine. Why? Because what is at stake is the vulnerability of the entire society to catastrophic epidemic. In that case, individuals must submit.

Which is why smallpox vaccines were mandatory when we were kids. It wasn't left up to you to decide if you wanted it. You might be ready to risk your life by forgoing the vaccine, but society would not let you not because it was saving you from yourself but because it had to save others from you. The problem wasn't you getting smallpox; the problem was you giving smallpox to others if you got it. Society cannot tolerate that. We forced vaccination even though we knew it would maim and kill a small but certain number of those subjected to it.

Today the case for mandatory vaccination is even stronger. This is war. We need to respond as in war. The threat is not just against individuals, but against the nation. Smallpox kills a third of its victims. If this epidemic were to take hold, it could devastate America as a functioning society. And the government's highest calling is to protect society a calling even higher than protecting individuals.

That is why conscription in wartime is justified. We violate the freedom of individuals by drafting them into combat, risking their lives suspending, in effect, their right to life and liberty, to say nothing of the pursuit of happiness in the name of the nation.

Vaccination is the conscription of civilians in the war against bioterrorism. I personally would choose not to receive the smallpox vaccine. I would not have my family injected. I prefer the odds of getting the disease vs. the odds of inflicting injury or death by vaccination on my perfectly healthy child.

Nonetheless, it should not be my decision. When what is at stake is the survival of the country, personal and family calculation must yield to national interest. And a population fully protected from smallpox is a supreme national interest.

If it is determined that the enemy really has smallpox and might use it, we should vaccinate everyone. We haven't been called upon to do very much for the country since Sept. 11. We can and should do this.