Volume 6 No. 2 - 2002
September 11: Everything Changed
By Daniel Epstein

Smallpox Nightmare

The ultimate nightmare of some health experts is a terrorist release of smallpox, a scourge that killed 3 million to 4 million people every year before it was eradicated more than two decades ago. If released in an international airport, for instance, the virus could infect people who would not show symptoms for days. Because the virus spreads through face-to-face contact, they in turn could infect many more people worldwide, initiating a full-blown outbreak of smallpox that would become an international health emergency.

 Smallpox victim
Smallpox victim, Zaire, 70s
(Photo ©PAHO/WHO)
There is no approved treatment for smallpox, and about a third of those affected by it die, although a vaccine administered even several days after infection can reduce its effects substantially. However, there is not enough vaccine in the world today for those who might be infected in a widespread attack. As a result, the United States and Canada are working to stockpile enough vaccine for their own populations, while countries in Latin America and the Caribbean, with support from PAHO, are exploring renewed vaccine production.

The eradication of smallpox in 1980, culminating a 12-year global effort led by the World Health Organization (WHO), is widely considered one of humanity's greatest achievements, marking the first time a disease was wiped off the face of the earth. But no one is certain who still has the deadly virus, apart from the two declared stocks in the United States and Russia. Former Soviet scientists say Russia continued biological weapons research after smallpox was eradicated, producing the virus at least into the 1990s. Some officials fear that scientists who worked on that effort might have sold the virus to terrorists or rogue nations.

 Last victim of Smallpox
The last recorded case of smallpox,
in Somalia in 1977, ended with the
patient's full recovery.
(Photo ©PAHO/WHO)
Ironically, the successful eradication of smallpox is what led to its potential use as a weapon; because vaccination ceased some 25 years ago, many-if not most-people today are susceptible to the virus (experts disagree on how immune those who were vaccinated still are). Some fear that the disease could spread rapidly.

How realistic is the smallpox threat? No one really knows. But Dr. D.A. Henderson, the physician who led the global smallpox eradication effort from 1966 to 1977, was concerned enough that he began warning about just such a threat in the early 1990s. A former dean of the Johns Hopkins University School of Public Health and currently an adviser to PAHO, Dr. Henderson founded and directed the Johns Hopkins Center for Civilian Biodefense Studies to carry out research on bioterrorism.

On Nov. 1, seven weeks and two days after the events of Sept. 11, Dr. Henderson was named to head a new Office of Public Health Preparedness for the U.S. Department of Health and Human Services. One of a select and tight-knit group of doctors who worked to rid the world of smallpox, Dr. Henderson says that more than anything, he would like to persuade the countries of the world to come together to condemn the use of germs as weapons.

"We've got to put the genie back in the bottle," he told The New York Times in November. The eradication program was an international effort, he points out, and other nations wanted the virus destroyed. "We had countries around the world saying, 'Why are Big Brother United States and Big Brother Russia keeping the virus?'" Clearly, there was a danger that the virus could escape, as it did in a laboratory in England in 1978, infecting a medical photographer. Moreover, he adds, by destroying its stocks, the United States could make possession of it a crime.

Dr. David Heymann, who worked in the smallpox eradication effort under Dr. Henderson and is now executive director for communicable diseases at WHO in Geneva, notes that in the event of a terrorist attack with smallpox, "the industrialized countries are, and will be, much better equipped to contain it than are developing countries." He adds, "It's not clear that we could muster up any will to do another eradication program. I think it would be hard to sell because if you do eradicate it again, you're in the same vulnerable situation we are in now."

 One of the last stocks of smallpox virus
One of the world's last known stocks of smallpox virus was stored
in this sealed refrigerator at a WHO Collaborating Center
in Moscow in the late 1980s. (Photo ©PAHO/WHO)
After the disease was eradicated, governments agreed to keep stocks of the live virus in two secure laboratories, one at the Centers for Disease Control in Atlanta and one in Siberia, Russia. WHO and others advocated complete destruction of the remaining stocks of the virus, but that position was contested by some U.S. scientists. In 1999, U.S. President Bill Clinton declared the smallpox stocks should be retained while more research was conducted. On Nov. 15, the Bush administration also decided that the remaining smallpox stocks should be retained, until new vaccines and treatments for the disease are developed-a process that is likely to take years.

Terrorism experts generally agree that the risk of using a weapon that could kill their own people would not deter some radical groups, especially those that are motivated by religious fervor. Mr. Michael Swetnam, chairman of the Potomac Institute for Policy Studies in Arlington, Va., says the possibility of a smallpox attack should be taken seriously. But he adds that other weapons, such as a conventional bomb, a chemical agent, or a different type of biological agent, are more likely to be used for the simple reason that smallpox is hard to get. Still, exaggerating the risk of a smallpox attack might not be a bad thing, Mr. Swetnam says. "If we blow it out of proportion and we make sure we stockpile enough vaccine for everybody, then there's no incentive for them to use it. It will cost us a lot of money, but it's buying insurance."

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Smallpox Redux

The number of individuals susceptible to smallpox infection today is larger than ever, given that immunization stopped more than a quarter-century ago, and very few people have natural immunity. Although smallpox is more difficult to release, its hazard potential is much greater than that of anthrax. Because it is highly contagious, smallpox would become an immediate international problem. Countries that in the past had the capacity to produce a vaccine against the disease are no longer able to do so, and regaining that capacity would require training and revision of production procedures. The United States has decided to restart the production of smallpox vaccine using the traditional New York City Board of Health strain of vaccinia virus. U.S. government scientists are also conducting studies to see if any existing antiviral drugs would work against smallpox.