-- At just past 1:30 p.m. yesterday, with the scent of lunch still in the air, James Hadler rolled up his sleeve, laid his arm on a table and officially launched the Bush administration's domestic war on smallpox.
More than a year in the making -- and 30 years after routine vaccination for the disease was halted -- the immunization of state epidemiologist Hadler and three other physicians marked a milestone in the nation's effort to protect against biological attack. Under the watch of federal health officials, security guards and a battalion of journalists, Connecticut became the first state to carry out President Bush's smallpox immunization campaign.
Within weeks, the administration hopes to inoculate as many as 500,000 health care workers -- a goal that may prove difficult, given what turned out to be a disappointing turnout here and reports from across the country that many medical professionals have been slow to embrace a policy with known risks and unknown benefits.
Officials expected 20 volunteers to be inoculated in Connecticut today, but only four showed up. Michael Grey, coordinator of the state's "Genesis Team," attributed the disappointing turnout both to complacency about a possible bioterrorist attack and to anxiety about receiving a vaccine known for its serious, even fatal, complications.
"There's not been a case of smallpox; we're not yet at war with Iraq. People's concerns are reasonable," he said. "We're ready to adjust to that." Later, state Public Health Commissioner Joxel Garcia said he did not really expect all 20 today.
A highly contagious disease, smallpox was eradicated worldwide in the late 1970s. Although there is no known threat of an imminent smallpox attack, Bush wants to vaccinate as many as 10.5 million medical workers and emergency responders who would have to investigate early cases and immunize others. Mandatory inoculations for 500,000 military personnel have been underway for weeks.
About 30 percent of the U.S. population should not be inoculated because they have at least one contraindication, or condition, that puts them at higher risk. They include people with skin conditions, pregnant women and people with weakened immune systems.
As the launch date drew nearer, a growing number of hospitals and medical groups decided not to participate -- at least for now.
Alabama initially planned to inoculate 12,000 people from 93 hospitals and local health departments in the first stage, said state health officer Donald E. Williamson. "It's going to be much lower," he said. "I wouldn't be surprised to see it in the 2,000 to 5,000 range."
Physicians said their main concern is for patients and family members who might inadvertently be infected by the live-virus vaccine. As a result, prominent hospitals such as Children's Hospital in Philadelphia, Vanderbilt University Medical Center in Nashville and Centura Health, a 10-hospital chain in Colorado, have decided not to immunize employees.
Still, two dozen states and Los Angeles County have requested a total of 127,000 doses of the vaccine from the federal government, and 29,800 doses had been shipped as of late today. Many states, including California, have said they need more time, while others, such as Ohio, Colorado and North Carolina, are scaling down their programs.
"We have a bigger threat with drug-resistant tuberculosis today than we do from smallpox," said Kay McVay, president of the 50,000-member California Nurses Association. "I'm wondering if this is not a little play to create some hysteria about the prospects of this horrendous disease and war."
Her organization, along with nurses' groups in Rhode Island and Massachusetts, advised members not to volunteer for inoculation. About nine Connecticut nurses backed out today because of warnings from their union, Grey said.
Michael Osterholm, a bioterrorism adviser to Health and Human Services Secretary Tommy G. Thompson, said he expects fewer adverse reactions in this vaccination campaign because officials are counseling volunteers about potential risks. But unions say the federal government should pay to test volunteers for contraindications, such as HIV, rather than simply talking to them.
And although many praised the government for providing liability protection for individuals and institutions administering the vaccine, there is still no compensation program for people injured by adverse reactions.
"I have an obligation to take care of my employees, and I have a problem possibly injuring a person who would not be compensated and whose family wouldn't be compensated," said Elizabeth M. MacNeill, chief medical officer of Pima County, Ariz., which includes Tucson. "Even though the risk is very small, it's unconscionable to take that risk with our valuable employees."
In most Arizona counties, MacNeill said, workers' compensation would not cover medical costs or lost wages if a person is injured in a voluntary program.
A recent survey by the Association of State and Territorial Health Officials found that few states are confident their workers' compensation laws will suffice. Connecticut is addressing that problem with state legislation that would provide compensation to anyone harmed by the vaccine, Garcia said.
"The goal is very simple: We have to protect our communities," he said at a news conference at which the speakers far exceeded the number of people vaccinated. Connecticut moved ahead rapidly to develop a terrorist response program after the Sept. 11, 2001, attacks because of the state's special vulnerabilities: proximity to New York City and its large number of universities, corporations and military institutions, he said. "We cannot wait for a case [of smallpox] in our country," Garcia added.
For today's volunteers, the hardest part was rolling their shirtsleeves high enough, joked Robert Fuller, 38, director of emergency operations at the University of Connecticut Health Center.
Hadler, the first volunteer, said he came forward because his job entails investigating possible cases, and he wanted to take the lead before asking other staffers to bare their arms.
Strictly speaking, he was the second. Marcia Trape, medical director for employee health at the school, was immunized hours earlier -- unseen by the news media.