President Bush's decision to make decades-old smallpox vaccine available to average Americans is raising alarm among health and bioterrorism experts who fear it will result in unnecessary medical complications and could divert resources from urgent national security needs.
Fearful that Iraq or terrorists may possess secret stocks of the deadly virus, Bush announced Friday an ambitious plan to inoculate as many as 11 million military personnel and emergency responders. He characterized the unprecedented program as a precaution aimed at protecting front-line personnel and improving response capabilities to a biological attack.
But even ardent supporters of that fundamental approach yesterday questioned the wisdom of offering the risky vaccine to all 286 million Americans as early as late spring.
"You have a disease that hasn't been seen anywhere in the world in nearly 30 years," said Carlos del Rio, chief of medicine at Grady Hospital in Atlanta. "The risk of the vaccine is higher than the risk of us having a case of smallpox."
Randall J. Larsen, a retired Air Force colonel and director of the ANSER Institute for Homeland Security, applauded Bush's announcement, saying inoculation of first responders was overdue. But he said he fears offering vaccine to every American will cause more problems than it might solve.
"I do not think it should be available to the general public any more than a person can walk into a pharmacy and say, 'Give me some penicillin and tetracycline,' " he said. "My concern is if a bunch of people go out and start taking it and you have this cute little fifth-grader that dies, it will be on the tube 24-7.
"Then people will stop taking it, including first responders and military personnel," he continued. "Then an attack occurs, and people will be slow to get it when they really need it."
Federal officials said they are not recommending everyone get the shot, made from live vaccinia that causes side effects ranging from a fever and rash to brain swelling and, rarely, death.
In a show of solidarity with the 500,000 members of the armed forces who will be inoculated, Bush said he will receive the shot. But he stressed that his family and staff would not be inoculated.
Several of Bush's health advisers said they did not know how the president arrived at the notion of providing unlicensed vaccine to those Americans who "insist" upon being inoculated. One administration aide privately expressed opposition, and federal bioterrorism adviser D.A. Henderson said the first time he heard the idea mentioned was in Friday's news briefing.
"The president was trying to be responsive to [requests from the public] but at the same time making it clear that based on the current level of threat, there is no reason to recommend the general public be vaccinated," said Jerome M. Hauer, acting assistant secretary at the Office of Public Health Emergency Preparedness.
Two influential advocates of offering vaccine to every American were Vice President Cheney and Sen. Bill Frist (R-Tenn.), a surgeon who recently wrote a book on bioterrorism. They and others argue for wide availability, for reasons of deterrence and democracy.
"This is not a public health problem, it's a national security problem and a terrorist threat," said Charles V. Pena, senior defense policy analyst at the Cato Institute. "While it's not happening as quickly as I would like, people should be able to choose for themselves and make an informed decision in a calm, rational manner."
Inoculating more people now -- especially doctors, nurses, police officers and firefighters -- would save time in the event of an attack, said William J. Bicknell, a former Massachusetts health commissioner. "The president's plan, particularly when it expands to the 10 million, takes the teeth out of smallpox as a terrorist weapon," he said.
Administration officials say they have attempted to strike a balance between the unknown risks of an attack with the smallpox virus and the dangers of the vaccine; between aggressive defense hawks and conservative public health leaders.
"For a public health response, I believe the first phase of 500,000 is an adequate protection level" to treat initial cases and run vaccination clinics, said Julie Gerberding, director of the Centers for Disease Control and Prevention. "I cannot say that would be adequate" if the nation's emergency response force is needed elsewhere, she said.
"This enhances our readiness to deal simultaneously not only with a mass vaccine program for the population, but also with some other terrorist attack or naturally occurring emergency," she said.
Still, many physicians worry that a major push to vaccinate against a disease that was declared eradicated worldwide in 1980 reflects a misunderstanding of true threats to America's health.
"I'd like the president to have an influenza vaccine campaign that's comparable," said William Schaffner, chairman of preventive medicine at Vanderbilt University Medical Center. "There's a disease that kills 10,000 to 20,000 citizens of the United States each year."
Grady Hospital's del Rio compares the Bush plan to advocating removal of everyone's appendix on the theory they might get appendicitis someday.
The current debate reminds Ivan C.A Walks of the dissension last year when the Bush administration offered anthrax vaccine as an experimental treatment to people who may have been exposed during the mail attacks -- but refused to make a recommendation.
"The Capitol Hill folks were offered appropriate, comprehensive medical follow-up, and the Brentwood [postal] folks were not," said Walks, who was the District's health director at the time. "Are all Americans going to get the same level of education about this choice? Will every American have the same opportunity for medical care?"