Because the smallpox vaccination program involved both public health and national security considerations, it is understood that the latter could involve classified information and thus limit what could be made available to the public. However, the apparent, unexplained constraints on CDC led to an environment in which the public health and health care communities and their leaders did not receive all the information needed to make institutional and individual decisions regarding smallpox vaccination (Selecky, 2003; Smith, 2003). There is little to suggest that the scientific and public health reasoning that typically characterizes the development of public health policies was a priority in this case. The expert input of public health leaders and other relevant constituencies was not reflected in the final structure of the smallpox vaccination policy. Agencies and organizations expected to be important partners in implementing the program expressed concerns and questions about it, and those concerns ultimately affected the program’s outcomes. Key constituencies remained skeptical about the need for the program, and their lack of buy-in led to poor participation in the vaccination program. At the institutional level, this is illustrated by the request of the Association of State and Territorial Health Officials (ASTHO) for an explanation of the rationale for the program (Selecky, 2003) several months after the beginning of vaccination. Among individual public health and health care workers, receiving what they perceived as insufficient information left them unable to accept smallpox vaccination.

Lack of Scientific and Public Health Rationale for the Existence of the Vaccination Program

In 2003, in Health Affairs, Kuhles and Ackman wrote:

The key message we received from potential vaccinees was that civilians are unlikely to voluntarily assume personal risk without good reason. Before performing an invasive procedure, physicians are required to undertake an informed-consent process with the patient, which spells out the indications, alternatives, and risks. The government owes its health care, public health, and first-responder communities the same consideration, particularly as it relates to the indications for vaccination, which thus far has been lacking.

Surveys of public health and health care workers (ASTHO, 2003; Everett et al., 2002; Yih et al., 2003), interviews (Kuhles and Ackman, 2003; Markowitz and Rosner, 2004), and newspaper articles (Associated Press, 2003; Bavley and Dvorak, 2003; Connolly, 2003a; Denogean, 2003; McCullough, 2003; McNeil, 2003; Ornstein and Bonilla, 2003; Wheeler, 2003) have shown that personal decision-making about smallpox vaccination was shaped by perceptions about known and considerable vaccine risk and unknown vaccine benefit in the absence of disease. The question of



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