sary to prevent the use of weapons of mass destruction. That clearly contentious matter was debated in Congress, in the mass media, and elsewhere. An attack on Iraq was argued on security, economic, foreign relations, military, and other grounds.

Although the federal government did not explicitly link the war with Iraq and the vaccination program and at times even denied that the rationale for the program was related to the rationale for the war, several officials (DHHS Secretary Thompson, CDC Director Gerberding, and CDC National Immunization Program Director Walt Orenstein) and legislators (Senators Bill Frist and Judd Gregg) made statements that could be interpreted as suggesting that the war was a factor in the decisions made about the smallpox vaccination policy and program or as asserting the importance of vaccination in view of developments related to the war and the possibility of a bioterrorrist attack (Frist, 2002; Gregg, 2002; Hallow, 2002; Manning and Sternberg, 2002; Pear, 2003; Rath and Turcotte, 2003; Tanner, 2003; Washington Post, 2002). Whether formally linked with the war or not, by its timing the smallpox vaccination policy was caught up in the larger debate with its emotional and polarizing consequences. Similarly, there was debate in some quarters about the efficacy and necessity of the vaccination program. According to the April 2003 General Accounting Office (GAO, now the Government Accountability Office) report, and to local health officials, hospital administrators, and others who were interviewed by the media or who addressed this committee, many people concluded that the risk of a smallpox attack was associated with the contentious war with Iraq (Anderson, 2003; Judson, 2003; Kuhles and Ackman, 2003; Krupnick, 2003; Manning, 2003; McKenna, 2003; McNeil, 2003). As the weeks passed, major combat in Iraq ended; the homeland security threat level, which had been increased before the war, was lowered; and the smallpox threat did not materialize. In September 2003, the U.S.-led Iraq Survey Group reported that it did not find weapons of mass destruction in Iraq; in particular, the group found no evidence of smallpox (Linzer, 2003; CIA, 2004; UN Security Council, 2004). Unfortunately, the smallpox threat assessment was neither updated nor reiterated, and that left many prospective volunteers in the public health and health care communities to draw their own conclusions about the threat status and may have further eroded their trust, given what they were (or were not) hearing from their federal-level partners. Those factors may have contributed to a waning sense of urgency; combined with concerns about cardiac adverse events, they go far to explain the declining rate of vaccination.

At the May 2003 meeting of the present IOM committee, ASTHO summarized what the nation’s health officials considered requirements for advancing smallpox preparedness, including a definition of the full scope of smallpox preparedness, a national consensus on who should be asked to



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