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Last Updated

30 Dec 2002

Source: Washington Post, February 7, 2002.

War and Health

By George F. Will, Columnist

War is unhealthy because of its violence, but also because of diseases spread by mass movements of men, often weary and sick, through disordered societies. Diseases arising from camp life, social disruption and unhygienic field hospitals have killed far more soldiers than has battle.

But modern war has driven dramatic improvements in public health, from Florence Nightingale's professionalization of nursing during the Crimean War to advances in surgery and control of infectious diseases. Because of today's war against terrorists, tomorrow's Americans will live better and longer.

That is the cheerful implication of the otherwise ominous fact that President Bush's budget asks Congress to more than quadruple spending -- from $1.4 billion to $5.9 billion -- on bioterrorism. Last week Defense Secretary Donald Rumsfeld was unspecific in saying "it is likely" terrorist attacks "will grow vastly more deadly" than those of Sept. 11. But budgets often make government's thinking clear, and the bioterrorism money may imply Rumsfeld's meaning.

Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health, says this infusion of money will accelerate our understanding of the biology and pathogenesis of microbes that can be used in attacks, and the biology of the microbes' hosts -- human beings and their immune systems. One result should be more effective vaccines with less toxicity.

Consider smallpox, one of the diseases at the top of the grim list of bioterrorist threats. The last U.S. case of smallpox was in 1949, but general vaccination of children continued until 1972. However, among every million people vaccinated, one or two died, so the vaccine was killing more than was the disease. Military vaccinations continued until the early 1990s, but now are restricted to special operations troops who might go places where bioweapons might be found.

The last recorded case of naturally occurring smallpox was in 1977 in Somalia. In 1979 the World Health Organization declared the world free of this scourge. But, says Fauci, it is "nonsense" to assert that the only remaining smallpox stocks are securely held in Russia and at the Centers for Disease Control in Atlanta. He says the Soviet Union made "vats and vats" of smallpox, some of which could have fallen into terrorists' hands.

Now, imagine something far more frightening than 20 hijackers flying planes into buildings. Imagine 20 fanatics willingly infected with smallpox and infiltrated into America. From history and from a contemporary experiment we have two appalling pictures of what might happen.

The picture from history is presented by historian Elizabeth Fenn's book "Pox Americana: The Great Smallpox Epidemic of 1775-82," published a few weeks after Sept. 11. Her subject is a war-driven epidemic -- notice that it coincided with the American Revolution -- that killed 130,000 and maimed many more, from Massachusetts to Mexico.

In 1775 the crucial determinant of vulnerability to smallpox was prior exposure to it. In England's congested cities, exposure was constant, so most adults were immune. Not so in thinly populated America. Before Washington was driven to inoculate his forces, immunity was concentrated among the affluent, such as John and Abigail Adams, who could afford inoculation. Washington's army was composed largely of poor men, so the British army was at first much less susceptible than Washington's. And Fenn says there is strong evidence that the British waged biological warfare, attempting to spread the disease in American ranks.

Fenn's history, with its stomach-turning descriptions of the disease's ravages, is particularly terrifying because America today, with urban congestion and no smallpox vaccination, is even more vulnerable to an epidemic than America was two centuries ago, when travel was not able to spread the opportunistic microbes across the continent in five hours.

Less than three months before Sept. 11 some national security specialists tried thinking the unthinkable. An exercise named Dark Winter postulated a smallpox attack in Oklahoma City. Smallpox has a 12-day incubation period during which infected people have no symptoms. For a few days following that, before definitive signs of the disease, the person is highly infective. So it can be spread widely before its existence is known. Dark Winter concluded that in just three months the attack would have caused a million deaths in 25 states.

The exercise indicated that the health care system lacks vaccines and other elements of a "surge capacity" to cope with mass casualties, and the political system lacks adequate plans for allocating care, imposing quarantines, controlling panic, etc. The president's proposed $5.9 billion is a bargain. It will improve public safety immediately and public health eventually.