The Smallpox Shuffle

iting terrorist threats, rogue nations and the specter of bioterrorism, President Bush kicked off a massive national smallpox vaccination campaign at the end of 2002. But just over a year later, the program has degenerated into a confused jumble of missed targets and conflicting public statements.

When federal officials launched the vaccination campaign in January 2003, public health officials nationwide scrambled to find funding, workers and resources to immunize some 450,000 emergency personnel in one month, and 10 million more by the end of the summer. Arlington County, Va., for example, was forced to curb home visits to at-risk infants and pregnant women, reduce the scope of school health programs and cut staffing at family planning clinics to try to meet the deadline. In Michigan, officials diverted funding from the development of their statewide health surveillance system.

But the immunizations have been wildly unpopular, and fewer than 40,000 medical personnel have received the vaccine. Yet in January 2004-after less than 1 percent of the vaccinations originally called for had been administered-Health and Human Services Secretary Tommy Thompson described the nation's smallpox preparation as "a huge success."

Critics say the Bush administration is trying to abandon a faltering program while simultaneously portraying it as a success. "The program is such an apparent failure," says Rep. Jim Turner, Texas, top Democrat on the Homeland Security Committee. "They need to step forward and either say we are going to get this back on track, or, if they have uncovered some information that says the threat is no longer serious, they have to come forward and describe that."

The smallpox virus could have a devastating effect on an unprepared society. In the 20th century, smallpox was responsible for 300 million deaths worldwide. Armed conflict killed 100 million during the same period. In one of history's most spectacular public health accomplishments, scientists and doctors eradicated the disease in the 1970s. Samples were kept at the Centers for Disease Control and Prevention in Atlanta and a laboratory in Russia. Homeland Security officials now are concerned that the virus might have fallen into the hands of terrorist groups or unfriendly states. Intelligence officials say the chance of a smallpox attack is low, but the stakes are extremely high.

Having failed to reach the goal for immunizing emergency workers, federal health officials have shifted their focus to responding quickly in the event of an outbreak. CDC Director Julie Gerberding is touting a different benchmark for readiness: States must be prepared to immunize their entire population in 10 days. According to Thompson, the "vast majority" of states are prepared to meet that goal. Homeland Security and CDC officials now say that 50,000 immunized workers will be sufficient to battle an outbreak.

The apparent U-turn on smallpox policy has left observers and local officials grasping for answers: Did the nation's most senior health experts actually misjudge the need for immunized personnel by more than 10 million? Were the immunizations a misdirected effort that pulled resources away from more worthy projects? Or was the program indeed necessary, but a failure, so it's being played down to avoid political embarrassment?

Rep. Richard Burr, R-N.C., a member of the House Permanent Select Committee on Intelligence, said in November 2003 that immunizations must continue. "There may be some people who choose to distance themselves from ever having said that vaccinations are needed," he said. "The reality is that the threat is every bit as real today as it was 10 months ago."

The program's defenders refuse to budge in the face of criticism. Liz Tobias, a spokeswoman for the Homeland Security Committee, says that people who question the altered vaccination targets are "getting down in the weeds" to criticize a "laudable goal." When asked if the shift from 10.5 million immunizations to 50,000 reflected a planning error, Tobias says, "I don't see that as a failure, I see that as an adjustment."

Thompson's claim that most states meet the 10-day goal is widely viewed as a tactic to deflect blame. His assertion is based on bioterrorism plans submitted to the CDC by each state, but those plans are classified and largely untested.What's more, there's a disconnect between Thompson's confidence and the cautious optimism of local officials. Government Executive spoke with public health officials from California, Florida, Michigan, New York and Virginia, and not one would make the 10-day guarantee. "That is a challenging goal," said Howard Backer, the acting immunization chief for California's public health system. "I'm not sure where they came up with 10 days just as I'm not sure where they came up with, 'We're going to vaccinate 500,000 health care workers [in less than a month].'"

State health officials, including Backer, did express confidence in their ability to respond to an outbreak of any sort. "We believe that we have a very powerful logistics system," says John Agwunobi, secretary of the Florida Department of Health. The Sunshine State has immunized almost 4,000 personnel-one of the highest per capita rates in the country-but when Agwunobi was pressed on the 10-day benchmark, he balked: "I don't believe the question has a yes or no answer." Virginia has held comprehensive smallpox response exercises with the CDC, but a top health official there also demurred on the 10-day benchmark. "I would be very skeptical of anybody who said, 'Yes, we are completely prepared,'" said Lisa Kaplowitz, deputy public health commissioner for Virginia's Emergency Preparedness and Response programs.

As federal health officials promote the 10-day benchmark, they increasingly are viewed as backing away from the immunization program touted just a year ago as vital to homeland security. Participation in the program is voluntary and low turnout always was a possibility. A combination of poor planning and some unforeseeable obstacles appears to have kept volunteers away. But those who took immunization seriously continue to ask whether the program was dropped because it truly was unnecessary or because it simply was too hard to do. And if it was necessary but too difficult, is America still vulnerable to one of history's most effective killers?