Smallpox: Is the Cure Worse Than the Disease?
In December, amidst widespread speculation that terrorist organizations and countries such as Iraq and North Korea may have their hands on the smallpox virus, President Bush unveiled a multi-phased plan of mass voluntary smallpox vaccinations for the nation's population. Somewhere behind the plan lies the notion that the threat is more than a mere possibility -- the belief that someone somewhere not only has access to the virus but also possesses the means of delivery, although little evidence has been shared with the American people.
While disturbing, this notion is not far-fetched. The use of smallpox as a biological weapon is nothing new. The British are believed to have used smallpox against the Americans in the late 1700s. Lord Jeffrey Amherst, commanding general of the British forces in North America, was accused of using smallpox-infected blankets as a means of germ warfare some 200 years ago in order to defeat Western Indian tribes.
An outbreak in Russia in the early 1970s was believed to have resulted from the testing of a weaponized version of the virus. Information from a top-ranking Russian defector in the early '90s served to confirm the speculation that Russia was toying with smallpox as a biological weapon.
Smallpox is difficult to acquire nowadays, though just how difficult remains to be seen. After its eradication, the World Health Organization ordered that all smallpox samples be destroyed or sent to one of two places: the Center for Disease Control (CDC) in the United States or the Research Institute for Viral Preparations in Moscow. The American stockpile is presumably secure; in 1994, the stockpile in Moscow was secretly moved to Siberia.
Whether every lab, hospital, and university worldwide complied with the WHO's request is another question.
Dr. Jonathan Tucker, the director of the chemical and biological weapons program in Washington, D.C. office of the Monterey Institute of International Studies and a former UN weapons inspector in Iraq, fears that Iraq my not have followed that order.
"Iraq has yet to account for what they claim to be the destruction of their stockpile," Tucker says. "They have the capacity to produce chemical and biological weapons. They have the know-how, the technology, and the raw materials."
For now, Tucker is not terribly worried that the disease will be unleashed. However, Tucker says, "If we go to war with Iraq, all bets are off. We could unleash a whirlwind and provoke Saddam to use these kinds of weapons. The risk increases substantially once he has nothing to lose."
That possibility is terrifying to the experts, because smallpox poses a uniquely virulent danger. There are some 281 million people living in the United States -- that number is dwarfed by the numbers of people who have suffered gruesome deaths at the hands of smallpox. Smallpox has claimed more lives than Black Death (Bubonic Plague) and all 20th century wars combined. There is no proven treatment. There is no cure.
With war in the Gulf looming, and the threat of terrorism haunting the nation, the Bush Administration has taken a monstrous leap -- implementing a voluntary smallpox vaccination plan for healthcare and emergency workers and later to the public at large.
Every county in the nation has been tasked with devising its own small- and large-scale vaccination plan under national guidelines. Monterey County's plan for all phases of the vaccination plan is in the works, though no definitive date has been set for its completion.
But as deadlines approach, and vaccinations get underway, the debate about whether or not smallpox is an actual public threat grows.
Some suggest that the mere possibility of the disease being released is reason enough for mass vaccinations. Others are urging a wait-and-see approach, given the vaccine's significant side effects. Who ultimately is right is anyone's guess. But a wrong decision either way is potentially fatal.
A Vile Virus
The Smallpox virus, or variola, has been wreaking havoc across the globe for thousands of years. Smallpox was written about by ancient Egyptians around 3700 B.C. and is believed to have existed as far back as 10,000 B.C. The virus pays no mind to social or economic boundaries. It kills 30 percent of its victims and leaves survivors blind or scarred for life.
The virus' origin is but supposition. Most experts opine that it originated in rodents, eventually jumping species into humans. (Most species carry some form of poxvirus -- there are foulpox, sealpox, foxpox, camelpox and kangaroopox.)
Smallpox has been responsible for the collapse of empires, the extinction of entire armies, the loss of wars. In his book "Scourge: The Once and Future Threat of Smallpox," Dr. Tucker points out that smallpox may have been at the root of the founding of such institutions as Harvard in 1636 and Yale in 1701 because, he says, smallpox was rampant in England, and sending young men away to Oxford or Cambridge at that time often meant their demise.
According to the CDC, smallpox begins and becomes contagious with the onset of flu-like symptoms of high fever and all-over body ache about two weeks after exposure. A few days later, painful blister-like pustules begin to form on the skin. According to Tucker, smallpox patients felt as if they were being consumed by fire.
Dr. Linda Velasquez of the Monterey County Health Department says the disease cannot be abated; the only treatment is supportive.
"If the patient is dehydrated, they can be hydrated; if they're running a fever, we can try to control the fever," she says.
Eventually, the pus-filled boils can multiply, spreading throughout the mouth, throat and surface of the skin to such a degree that each pustule abuts the next, and the entire surface of the skin is raised. When the bumps have filled to capacity, they burst, spilling foul-smelling yellowish contents onto linens, rendering even those highly contagious. In a matter of days, the open wounds scab over and fall off, leaving the skin with deep, pitted, disfiguring scars.
Two lesser-known forms of the virus are particularly lethal. Hemorrhagic smallpox has the appearance of dark, purple bruises, the whites of the eyes black with blood. In a short time, the victim bleeds uncontrollably. Malignant smallpox is similar, the lesions of the skin velvety in texture. Both forms are close to 100 percent fatal.
Tucker says that victims of smallpox can remain contagious for a period of time even after death.
"Even corpses buried in the permafrost hundreds of years ago can still be contagious," he says, adding that because of the risks associated with transmission after death, remains of smallpox victims need to be cremated.
According to the WHO, one case of smallpox anywhere in the world would be considered a worldwide medical emergency.
The United States experienced its last outbreak of smallpox in the late winter of 1949. The virus continued in various places of the world for close to 30 years until Ali Maow Maalin, a young cook and smallpox vaccinator in Somalia, became the world's last known case of endemic smallpox. He survived.
Finally, on September 11, 1978, Janet Parker, a medical photographer in Birmingham, England, died as a result of the smallpox virus she contracted weeks earlier from a laboratory accident. The virus escaped into the air at the hands of a poxvirus researcher by the name of Henry Bedson, who later committed suicide over the incident.
With Parker's death came the end of a chapter in the smallpox virus' centuries-long history. In May of 1980, after an exhausting worldwide effort initially called for by the Soviet Union in 1958, the WHO declared smallpox eradicated from the planet.
For 25 years, the world was sanguine. But fear of smallpox has returned.
Some experts believe that the virus has been manipulated into a more virulent form. One informant told the CIA that particularly "hot strains" of smallpox had been acquired by Iraq as recently as the early '90s, from a Russian virologist who worked at the Moscow storage facility.
Dr. Richard Pilch, biological weapons expert at the Monterey Institute of International Studies, says: "Apparently, they inserted a gene to make it a very, very hemorrhagic form so you would bleed more, and there would be a shorter period before the onset of symptoms." Some reports put the death rate of hot strains of the virus up as high as 90 percent.
A Risky Vaccine
As long as smallpox threatened the world, someone somewhere was trying to stop it. History is replete with tales of society's desperate attempts to cloak itself in protection from the disease. Ultimately, a prevention was discovered.
Until the smallpox vaccine was discovered, folk remedies proliferated: olive leaf extract, horse excrement, sugar-free lemonade, wine vinegar, oregano, lemons. For a time, the belief persisted that the color red had healing powers and, if a victim was wrapped in red cloth and surrounded by the color and even heated by a fire, the demons of smallpox could be banished.
Later, a rudimentary form of vaccination was practiced. "Variolation" involved snorting the scabs of victims, and was believed to prevent the disease. Oftentimes, though, the person being inoculated would contract the disease and suffer its consequences.
In May of 1796, a physician named Edward Jenner, believing that dairy workers were becoming immune to smallpox after contracting cowpox, a milder poxvirus, and infected a boy with cowpox. He waited a period of weeks and then subjected the boy to smallpox. The test (while highly unethical by today's standards) yielded positive results: the boy did not become infected with smallpox.
With his discovery, Jenner coined the term "vaccine," from the Latin word vacca. meaning cow. The smallpox vaccine had been discovered.
The vaccine was distributed worldwide, and did its job. In the U.S., the vaccine was widely used until the early 1970s. As a result, most people over the age of 35 carry an unmistakable circular scar on their upper arm or, less commonly, their leg or shoulder blade, caused by the multiple stabs by the vaccine's bifurcated needle. Those under 35 -- about 45 percent of the population -- have not been vaccinated.
Even those who did receive the vaccine likely have little to no immunity left. According to Pilch, the vaccine loses its potency after five years, waning to close to zero-percent effectiveness after about ten years.
Because of its propensity for adverse side effects, including death, Pilch says as much as 50 percent of the population will be unable to receive the vaccine when it becomes available to the public later this year. Among those contraindicated for the vaccine would be people with weakened immune systems, those with eczema, pregnant or nursing women, and children under 18. Pilch goes on to say that even those living with someone with such conditions would be ill-advised to get the vaccine. Though in an emergency, he says, everyone should be inoculated.
Phase 1 of the plan, already underway, will include about a million people, from military personnel to first-responder emergency healthcare workers. Military personnel began receiving vaccinations in December. According to a report in the Associated Press, some one-third have been deemed ineligible because of contraindications.
Dr. Velasquez says that Phase I of the plan has not yet yielded any inoculations in Monterey County, though she expects the specifics of the plan to be outlined soon and voluntary vaccinations to begin thereafter.
Though Pilch and Velsquez both agree that Phase I makes sense, Tucker is a bit more skeptical.
"It's the hardest type of policy decision there is," he says. "It involves imponderables. There's a low probability but a very high consequence. Ultimately, I think smart people can disagree on who should be vaccinated. The smallest number is best."
Pilch says he understands the concerns of those who would be included in Phase I. "They're saying, 'Why are we the guinea pigs?,'" he says. "But really, it makes sense to at least implement the first phase. Without the vaccination, if someone presents at an emergency room and winds up having smallpox, those emergency room workers have about four days before it's just too late. Five at best."
Wendy Oliva, Director of Infection Control Services at Salinas Valley Memorial Hospital, is acting as a liaison between the Health Department and the hospital. "I absolutely think we have the resources necessary to make this plan work," she says. "We're trying to help the staff feel more comfortable by educating them."
Phase II, expected to begin in early spring, will include about 10 million people: the remainder of emergency workers, as well as police, fire, and ambulance workers.
Pilch leaves his support behind when it comes to Phase II of the plan. He does not believe the threat warrants the effort.
"That's a significant blow to healthcare resources," he says. "Some counties are holding off on pap smears and mammograms for low-income women. I believe in preparedness, but not a misallocation of resources."
It is anyone's guess when Phase III-voluntary vaccinations for the public at large-will be implemented. But experts are eager to voice their dismay at the prospect. Pilch is blunt in his assessment that the move is politically motivated.
"I have large reservations about making a major vaccine voluntary to a public that's not informed" he says. "This is devised so it removes the liability of the Administration; that's all."
Worse Than the Disease?
Most experts agree that the first line of defense in a voluntary vaccination program is education, and that the component needs to be ramped up.
"The educational part needs to be put out there and properly, so we don't scare people into thinking, 'My God, the sky is falling,' when it's not," says John Calzada of the Monterey County sheriff's department.
Harry Robins, Director of the county's Office of Emergency Services (OES), agrees. "The education has to start nationally and go local," he says.
Calzada and Robins are working in conjunction with the Health Department to conjure up a plan to address Phase III, as well as an emergency vaccination plan. Robins hopes the solidification of the emergency plan will be forthcoming in the next few weeks, though no date has been established.
Since the Sheriff's Office is the primary law enforcement agency in the county, it has fallen onto Calzada's shoulders to help determine where mass vaccinations, if necessary, would take place. Among the factors that need to be considered are parking, safety, containment, and convenience. "We've considered places like the fairgrounds and the Rodeo Grounds because they're already geared with great numbers of people in mind," he says.
The Sheriff's Office would then bring in whatever other agency may be necessary jurisdictionally. "We've also got to consider the protection of medical staff, security of the vaccine, and crowd control," Calzada says, "and we can't do it alone."
Velasquez, Calzada and Oliva each say they believe that the county has the resources available to address an emergency, should it arise.
Robins is a little more reluctant about whether or not enough resources exist locally. "The one thing I do know for sure, though, is that I feel positive about what we're doing," he says. "I wish we didn't have to, but we can make it happen. We're all in this together, and nobody's going to stand alone."
Although they have been downplayed, the risks of vaccination concern most experts. Pilch says that as long as he's in the private sector and not practicing medicine, he won't be vaccinated.
Velasquez concurs, and doesn't recommend vaccination for the general public. "At this time, with the knowledge we have, the risk of the general public getting smallpox is remote," she says.
Wendy Oliva has yet to decide whether or not she'll get the vaccine.
"I'm trying to make that decision," she says. "Actually, I'm trying to think of why I can't. Just like any decision we make, we have to weigh all sides," she says.
Robins, who would be a first responder in an emergency and who's received the smallpox vaccine many times throughout his life and military career, says he'll be the first to get in line for the vaccine when it becomes available. "Sure, no problem," he quips.
Tucker, however -- the man who wrote the book on smallpox -- says that he'll forego the vaccine, "unless the threat situation changes significantly, at which point I'll reconsider. Right now, I believe the risks associated with the vaccine far outweigh the risks of contracting the virus."
Michelle Caldwell is a writer in Monterey County.