As commander in chief, President Bush has decided the risk of a smallpox terror attack on Americans is high enough to justify a nationwide vaccination program.
In announcing the program Friday, Mr. Bush is expected to require about 500,000 military personnel to be vaccinated. He's left it up to the states to propose which frontline hospital and health workers will be asked to volunteer for the program, while all other Americans can choose to participate - or not.
His wise choice of limited inoculations is based on past experience - and a limited supply of the licensed vaccine. The US ended widespread smallpox vaccinations in 1972, and smallpox itself was deemed eradicated in its natural form worldwide in 1980. The immunizations are considered fatal for about one or two people per 1 million vaccinations. That's a tiny percentage, but Bush decided that even at that risk, and because of concern for the possibility of severe side effects for a small percentage of the population, the scope of vaccinations would be in phases and voluntary.
Generally, the Centers for Disease Control and the Department of Health and Human Services prefer a voluntary approach because, for one reason, it encourages greater compliance. This voluntary aspect of vaccinations is important to many Americans who have religious, philosophical, or medical reasons to opt out of such a government program, especially in peacetime.
Under the Constitution, states are responsible for public health, and each of them has varying laws on how to deal with emergencies and vaccinations. A majority of them have laws that respect an individual's right to use alternatives to vaccinations, such as prayer, or other healthcare approaches. The Bush administration is wisely working with state health departments to come up with a smallpox vaccination program that would honor this right.
One reason for caution regarding mass inoculations can be found in the experience of one Pentagon program in 1998. All 2.4 million active and reserve troops at that time were ordered to receive the vaccine for anthrax, a substance which, unlike smallpox, is not communicable.
Controversy over that vaccine's safety and effectiveness prompted Congress to recommend suspending the program in 2000. The Defense Department did ratchet down its program during that peacetime period, but mostly for supply reasons. Then, in the wake of Sept. 11 and the war on terrorism, it stepped it back up last June, though this time mandating it only for troops assigned to "higher threat" areas.
The government insists the anthrax vaccine is safe, but hundreds have been forced out of the military for refusing it, and the fear factor is substantial, according to the US General Accounting Office. This federal watchdog reports that the vaccine program has driven critical National Guard and Reserve pilots from their posts. If the vaccine were voluntary, a stunning 77 percent of the Guard and Reserve members would have declined it, the GAO found.
In Congress, lawmakers plan to revisit the issue of vaccine liability early next year. While they are doing that, the nation's oldest vaccine safety advocacy group, the National Vaccine Information Center, also wants them to reconsider a section of the new Homeland Security Act which gives the Secretary of Health and Human Services sweeping powers to declare bioterrorism emergencies and decide on an appropriate response. The group wants to make sure that if a response involves mandatory vaccines, exemptions be allowed at the federal level just as they are in many states.
The new homeland law raises the profile of the federal government as an emergency coordinator because healthcare in wartime can't be approached in the same way as before Sept. 11. Lawmakers, and groups that advocate exemptions, must be sensitive to the government's need to respond to wartime emergencies.
From the medical point of view, for instance, different diseases require different vaccination participation rates - one more reason the government should move forward cautiously, on a case-by-case basis, as it is with the smallpox vaccine.
In the meantime, citizens should cooperate with all government health officials to avoid raising alarm. Caution, rather than fear, should guide the nation to act in the face of a bioterror threat.