In December, when hospitals in Atlanta and Richmond announced that they were opting out of the federal smallpox vaccination plan, opinion leaders reacted as if the physicians had enlisted with Al Qaeda. The Washington Post argued that “there are reasons, moral and medical, to deplore the decision of those doctors who refuse in this manner.” A New York Times editorial called the decision “deplorable.”

In the months since, hundreds of other hospitals, asked to employ a famously risky vaccine against a disease that was eradicated twenty-six years ago, made the same “deplorable” decision. But by late March, when a nurse, a nurse’s aide and a National Guardsman all died of heart attacks following vaccination, the hospitals’ resistance seemed less deplorable than prescient. Once news of the deaths broke, at least ten health de-

partments temporarily suspended their smallpox programs. Under the Administration’s plan, half a million emergency room workers were supposed to have been inoculated by late February. But as of March 28, only 29,584 doses of vaccine had been administered. The White House’s immunization blitz is a bust.

The vaccination of ER workers was supposed to be only Phase I of the smallpox plan. Phase II would have given the vaccine to 10 million first responders, such as emergency medical technicians, fire departments and police. Phase III would offer the vaccine to any anxious Americans, if not medically disqualified–the approach originally advocated by Vice President Cheney. If individual hospitals and health departments hadn’t stood their ground, the vaccination death toll could have been higher.

With any therapy or preventive treatment the question is always: Do the benefits outweigh the risks? Measuring a bioterror threat that was merely theoretical against the vaccine’s known risks of illness and death, most healthcare workers said no. They weren’t primarily fearful for their own lives–though even healthy people who get smallpox vaccinations risk encephalitis and ravaging skin infections–but rather for their patients’.

What healthcare workers see when they stroll through hospital corridors are not victims of biowarfare but patients suffering from cancer, heart disease, HIV infection, diabetes, organ transplants and other immunity-dampening conditions. The smallpox vaccine is made from vaccinia–a live, transmissible, potentially deadly cousin of the smallpox virus. That means fragile patients could actually get infected by freshly immunized healthcare workers whose vaccination sites are not well sealed.

In refusing to be immunized, doctors and nurses not only protected themselves and their patients but also shielded institutions from potential lawsuits over death and injury, a problem the Bush Administration neglected for months. Not until early March, with war looming, did the White House ask Congress to authorize compensation for vaccine victims. Even that package, derided by Senator Ted Kennedy as a “tin-cup response,” doesn’t come close to covering the full risks of the misconceived program. “What happens if a family member gets sick?” asks Cheryl Peterson, RN, a senior policy analyst with the American Nurses Association, which criticized the smallpox program. “What happens if a patient of mine gets sick? What happens if I get sick? Where is the government going to be?” Three deaths later, legislators have yet to pass a compensation package.

The President’s plan was never a traditional public health initiative. Childhood immunizations against measles and mumps, or hepatitis B shots for healthcare workers, protect people against clear and definable risks and offer irrefutable public benefits. In this light, the smallpox program, says Brian Strom, MD, chairman of a prestigious Institute of Medicine committee advising federal health officials on the smallpox plan, “is not a public health campaign at all. It’s a defense program.”

Most health experts acknowledge that there is a remote risk of a smallpox attack. Among the four nations suspected of harboring secret stocks of the virus are Russia, North Korea and Iraq. Still, many doubt the Bush team’s motives and its credibility in assessing the threat. “The Administration says, ‘We know but we can’t tell you,'” says Linda Rosenstock, MD, dean of the School of Public Health at the University of California, Los Angeles. “They say there’s nothing to worry about at the same time that they’re recommending an extreme policy.”

The vaccination plan was politicized from day one. Shortly after 9/11 Senator Arlen Specter volunteered his four granddaughters for inoculation; last August, Senator Bill Frist argued that all Americans should be able to get the vaccine.

“The Administration covered itself,” says Paul Offit, MD, a member of a federal advisory committee on immunization. “If smallpox virus comes into this country, they’ve made every effort to try and get people vaccinated. And if it doesn’t come into this country, they can claim it was a deterrent. But this is not the vaccine to use as a deterrent.” Some doctors resisted taking part in the program because it would have made them complicit in a war they abhor. Ira Helfand, MD, chairman of emergency medicine at Cooley Dickinson Hospital in Northampton, Massachusetts, which opted out in January, says many on his staff saw the plan as “part of the Bush Administration’s effort to build up a climate of siege in this country to support his policy in Iraq.”

The Centers for Disease Control and Prevention appear to be caught between Washington hard-line politics and more measured advice from other public health veterans. Though the CDC added heart disease to the exclusion criteria for the current smallpox program, it nevertheless plans to move forward, releasing Phase II guidelines by mid-April. But Offit, the only federal adviser to vote against the plan in October, argues that we should “use the recent events as a reason to temporarily suspend the program and take a step back.” Strom, who was alarmed when some states quietly started up Phase II in early March without first examining Phase I’s failures, has also come around to supporting a “pause.”

With risks more severe than had been anticipated, their words should be heeded. In truth, the government may not need to immunize anyone yet. The vaccine is protective even four days after exposure, which weakens the argument for putting such a dangerous vaccine into people’s arms now. As long as the vials are strategically in position, there would be time to respond if and when the unthinkable occurs.”