decision-making process at the highest levels of government. A lack of information about the development of health policy does not always provoke concern. However, the nature of the decisions about the smallpox vaccination program use of a vaccine with known potential complications to protect against an eradicated disease has brought into question the evidence, data, and reasoning that contributed to the fashioning of the final policy.

Rationale for the Policy

The smallpox vaccination policy announced in December 2002 was unusual in bringing together a national security program with a public health strategy. The president stated on December 13, 2002, that “we believe that regimes hostile to the United States may possess this dangerous virus” (White House, 2002). The initial policy announcement and later clarifications by DHHS provided little information about the threat assessment other than reassuring the public that there was no information to suggest that a smallpox virus release was imminent. The combination of known vaccine-related problems and unmeasurable disease threat was deeply problematic, and was reminiscent of the challenges faced by decision makers who planned the swine influenza campaign of 1976 discussed in Chapter 4.

The intelligence considered in the development of the policy was not shared with the public or with those who would be called upon to respond to a smallpox event. However, coverage in the print and broadcast media provided fragments of information about intelligence and speculation about the suspected location of smallpox virus around the world. In 2002, the mass media reported that two unnamed U.S. government officials who had received classified briefings revealed that the federal government had information about Iraq’s possession of smallpox virus. Other news reports suggested that North Korea, Iraq, Russia, and France might possess stocks of smallpox, and reported on the smallpox vaccination status of Iraqi prisoners of war, and reported on other possible indications that the Iraqi bioweapons program included smallpox (Boyle, 2002; Gellman, 2002).

In fall 2002, the possibility of war with Iraq loomed, owing in part to fears that Iraq possessed weapons of mass destruction. At the same time, the federal government named Iraq as one of the nations suspected of possessing smallpox stocks that could be used in a bioterrorist attack (Manning and Sternberg, 2002; Meckler, 2002b; National Journal Group, 2002). This may help to explain the perception of many in the public health and health care communities that the government’s decisions about the Iraq war and some of the considerations leading to the smallpox vaccination policy were associated in some way, and this perception later influ-

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