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Copyright © 2002 International Herald Tribune
Wednesday, May 29, 2002
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As Pentagon officials ponder invasion plans for Iraq, U.S. public health officials are debating an issue whose outcome could make such an invasion politically impossible. It is the question of whether to launch a wide-scale vaccination program in the United States against smallpox - historically one of the most devastating diseases known to humanity.

The reason: U.S. government planners believe that the principal threat to America from smallpox is not the danger posed by some future terrorist organization, but by Iraqi dictator Saddam Hussein. If inoculations are widely administered in advance of an actual outbreak of the disease, even on a voluntary basis, they would become "the shots heard around the world." Other countries would urgently seek to follow America's lead and some would feel highly vulnerable until they had done so.

Saddam is known to have had an extensive, moderately advanced biological warfare program that included the weaponization of anthrax bacteria, among other agents. There is no direct evidence that Iraq weaponized the smallpox virus, but Iraqi specialists are known to have been working with the camelpox virus. The virus may be used as a surrogate for research on smallpox therapies and vaccines - and for the development of the smallpox virus as a weapon.

Although the World Health Organization declared smallpox eradicated in 1980 some of the last naturally occurring cases of the contagious disease were in Iraq, in 1972, when the Ba'athist regime, which Saddam would later head, was consolidating its power. The outbreak may have provided the Iraqi regime the opportunity to obtain and secretly hold onto cultures of the virus - the cause of a disease that over the centuries killed up to 30 percent of those infected and left many of the survivors disfigured with pockmarks, most prominently on the face.

What most troubles U.S officials today, however, is the fear that the Soviet Union may have shared with Iraq smallpox that it weaponized by the ton in the 1970s and 1980s. Some analysts consider this possibility far-fetched, but it appears to underlie Bush administration thinking on the issue.

It is also widely believed that during the 1991 Gulf War, Saddam pre-authorized commanders of his missile forces to launch chemical and biological weapons toward Israel and Saudi Arabia if it appeared that U.S.-led coalition forces were marching on Baghdad in an attempt to depose the Iraqi regime. Presumably, if the U.S. were to invade Iraq to achieve "regime change," Saddam would give such doomsday instructions again.

While successfully dispersing smallpox with ballistic missiles may be beyond Iraq's technical capabilities, Saddam could easily send secret agents abroad to disperse the virus through spraying systems in vehicles or small boats, or even by hand in busy markets, terminals or sports arenas.

Days would elapse before an outbreak were detected, during which, given the mobility of modern societies, the infection could spread to dozens of new locations - in potentially dozens of countries.

Current U.S. policy is to administer inoculations after a smallpox attack, around outbreak sites. But critics fear that such "ring inoculation" could never catch up with a malicious, multi-site attack. Switching to significant advance inoculation could carry heavy costs from side effects: one or two deaths per million recipients of the currently available vaccine, as well as probably hundreds of cases of dangerous non-fatal side effects.

A new, safer vaccine or voluntary vaccination that excluded those most vulnerable to side effects would save lives, but would do little to avoid the spectacle of America mobilizing to protect itself from the smallpox hazard.

Imagine if at the same time that it launched a significant smallpox vaccination program, the United States also began large-scale military preparations for the invasion of Iraq. Inevitably, other countries, particularly U.S. allies in the region, would demand the opportunity to immunize their populations before war with Iraq broke out.

Unfortunately, immunization campaigns by U.S. Middle East allies might take years to complete, assuming sufficient vaccine were available. How would the Bush administration respond to this conundrum? Would the U.S. invade Iraq, if Turkey or Egypt, for example, were not adequately immunized? Who would immunize stateless groups, such as the Iraqi Kurds and Shiites - or the Palestinians?

As the international community began to appreciate the biodangers of a U.S. invasion, Washington would face a global outcry demanding that it halt its planned assault until states in the region and, perhaps, beyond were smallpox-safe. The invasion would become politically impossible.

In addressing this smallpox paradox, President George W. Bush must act immediately to include national security officials in the current deliberations on vaccination policy and in framing all public pronouncements on the issue.

Second, the administration must provide a convincing assessment of the Iraqi smallpox threat. The U.S. is not known to have vaccinated its troops stationed near Iraq, despite periodic American bombing of that country over the past 10 years. There is no direct evidence that the Saddam regime actually possesses the virus. On the other hand, guessing wrong and failing to act could lead to catastrophe.

Finally, given the uncertainty about the magnitude of the smallpox threat, less vaccination is probably better than more for now. With some thought, we can probably identify a small fraction of the population whose vaccination, along with other preparatory measures, will help improve national readiness - without triggering undesired repercussions abroad.