From: "Larry Brilliant" <firstname.lastname@example.org>
Subject: Jon Carroll. Smallpox: why I will not vaccinate my family---yet. The Boffa Newsletter. Annual mailing list clean-up.
Date: Thu, 2 Jan 2003 23:25:12 -0800
Dear Reader of Jon Carroll's columns,
Attached below is the original smallpox essay Jon referenced in his column today. Like you, I am a great fan of his column. I hope this essay is of use to you. For those of you who requested permission to reprint the essay below or put a copy on your website, permission is granted. You may want to see another version of it in the form of a letter to President Bush at www.edge.org which I think will be up on Monday, January 6th.
Happy New Year...and many prayers for a year of health, happiness, and most of all, Peace.
From: Larry Brilliant [mailto:email@example.com]
Sent: Wednesday, January 01, 2003 5:00 PM
Subject: Smallpox: why I will not vaccinate my family---yet. The Boffa Newsletter. Annual mailing list clean-up.
Attached below is the 87th issue of the Boffa newsletter.
I started writing Boffa shortly after September 11th, when I resigned from all of my corporate boards of directors, volunteered to be a "first responder" for smallpox bio-terrorism at CDC, and quickly realized that because of my "eclectic" background (a euphemism for "strange and unusual"---as a physician epidemiologist who lived in India for a decade, CEO of public companies and an old hippie)--- I had a very different perspective about international relations, bio-terrorism, and the clash of cultures. Previous Boffas have been about smallpox, the Gospel of Mark, Attorney General Ashcroft vs.Civil Liberties, Buddhist ethics, India, patriotism and how much I love the essays of Thomas Friedman.
Boffa now has nearly 5000 readers or "subscribers." Of course, it is completely non-commercial and free.
Usually, I attach some interesting article to a brief introduction to try stir up deeper reflection. Of course, I often fail. The issue attached below, which I sent out a few days ago, is quite a bit different because so many people asked me to, and I felt an obligation to, write in some depth about the pros and cons of getting smallpox vaccination.
Many of you already get the newsletter. For some, this will be your first "issue". This New Year's Day, I am cleaning the mailing list--if you would like to be deleted from the list, now is a great time to let me know: just a simple email will set you free. If you receive Boffa at more than one email address, please let me know which email address you wish to continue getting the newsletter at.
If you would like to add friends to the mailing list, this, I only do it infrequently, so this would be a good time to forward this issue to them, or send me their email addressed to be included, They need never know that it was you who foisted Boffa upon them.
Either way, have a happy, loving, healthy--and most of all---peaceful New Year.
You know this old puzzle: You are a farmer by a river with a fox, a chicken and a bag of grain. There is a boat with which you may move yourself plus any one of these items at a time to the opposite bank. You must move all three items from the left to the right bank without leaving the fox alone with the chicken or the chicken with the grain for obvious reasons. Note that the fox is not particularly partial to grain, and may be left alone with it. Take a few minutes on this puzzle (the answer appears at the end of this Boffa).
And now think about another, far more important, twister: Whether to vaccinate your family based on the limited and conflicting data we have on Al-Qaeda, the Russian smallpox weapons program, Iraq ......can we use logic to puzzle our way out of this dilemma?
During the past several months, I've been frustrated by the smallpox puzzle and the accompanying national agony about vaccination . Dozens of Boffa readers have asked me to write something, dozens more have cornered me asking "what should I do about vaccinating my family" or, more pointedly: "are you or your family getting vaccinated?"
I was vaccinated against smallpox hundreds of times in the smallpox program in India, and again by CDC last year during the "smallpox bio-terrorism" sessions for first responders. My children, wife, mother, brother and neighbors have not been recently vaccinated and I do not recommend it, at least not yet. Based on the risks and benefits of what we know today, I do not recommend anyone rush out to get vaccinated unless they will be a "first responder" or work in a hospital emergency room.
Why? My decision is based on trying to solve as many simultaneous equations as are needed to solve the puzzle of the farmer, the fox, the chicken and bag of grain. But unlike that puzzle, the smallpox dilemma has no simple answers, and making the correct decision may, literally, be a matter of life and death for you and your family. I feel an obligation to put into your hands enough information about the smallpox dilemma, accompanied by the best readings and references I could find so you can think through the issue and make your own informed decisions. I've been struggling to find the time to organize the most recent best material. Please forgive me if what follows is disjointed, too much information, or too poorly presented.
The facts today: Smallpox as a disease does not exist. It has been eradicated. A very small amount of the virus which causes smallpox, Variola, has been held frozen in liquid nitrogen in two "legal and secure" facilities in Atlanta and Moscow, as agreed to by the 150+ member states of the World Health Organization. It is easy to "awaken" the demon of smallpox if it is removed from these freezers. Except for a very controversial and potentially destabilizing removal last year of some viral material by U.S. Army scientist Peter Jahrling who used those viruses to infect monkeys with smallpox with the thought of testing smallpox anti-viral agents and improved vaccines (see Preston's book, below) all the other legal viral samples remain in place. The fear of smallpox as a weapon of mass destruction in the hands of terrorists is based either on the public information, which is speculative and anecdotal, or on military or secret intelligence sources which are unavailable . Vaccination of 280 million Americans could cause potentially fatal vaccine side-effects in tens of thousands and death in 500 to 1000. In order to justify so many vaccine side-effects, there must be real evidence of incremental risk of an epidemic caused by vaccine-preventable smallpox. There are at least three gating items, all of which must be true before it is logical to begin vaccinations against a disease which does not exist:
Gating item #1: Smallpox virus must exist outside of the two "legal and secure" repositories where, with the only known exception being the Jahrling experiments, it has resided securely for nearly three decades.
Gating item #2: That smallpox virus which is outside of the two "legal and secure" repositories must have reached the hands of terrorists or nation-states that would use smallpox in war.
Gating Item #3: That smallpox virus which is outside of the "legal and secure" repositories, in the hands of terrorists with an intent to use it, must not have been genetically altered so as to be impervious to the vaccine we currently have.
As is quite clear from Richard Preston's frightening book "Demon in the Freezer" (see below), Jonathan Tucker's scholarly book "Scourge", Ken Alibek's tell-all book "Biohazard", the NY Times reporting of Judith Miller and the Wall Street Journal reporting of Marilyn Chase and as well as countless reports from epidemiologists and bio-terrorism experts, Gating Item #1 appears to have occurred---Russian scientists operating under a Gorbachev approved billion dollar 5-year plan manufactured as much as 100 tons of Variola virus annually at a then secret facility called, ironically, Vector, near Novosibirsk, Siberia in the Soviet Union during the 1980's. There may have been other programs that have remained secret, just as the CIA program "Bacchus" to build a miniature anthrax production lab stayed secret virtually until the anthrax attacks of 2001.
There is no public knowledge, and I stress "public" for obvious reasons, that Gating Item #2 is true. The major known sources of concern are:
a) Saddam Hussein used saran gas and anthrax in missiles and shells and attempted to use Camelpox in horrid experiments against the Kurds. Logic dictates that if he does have smallpox, he is a serious threat to use it as a "doomsday" weapon.
UNSCOM photo of Iraqi Scud missiles with Anthrax nosecones
122 mm rocket shells filled with Saran gas, found by UN inspectors
b) Weapons inspectors found a refrigerator in Iraq, "ominously" labeled "smallpox" during the last round of inspections--we do not know if the "smallpox" referred to the disease of smallpox or the vaccine against it, but there were active cases of smallpox in Iraq as late as 1972 and there is no reason to believe harvesting viral specimens from those cases was not done. Iran, Iraq's neighbor and sometime enemy, certainly hid cases of smallpox from WHO inspectors (I was one of these) as late as the Shah's ceremonial coronation in 1972-73. When Iran and Iraq went to war a few years later, Saddam Hussein had reciprocal regional reasons for hoarding the Variola virus.
c) Al Qaeda documents, including some found on a personal computer purchased by a Wall Street Journal reporter, contained references to smallpox as a weapon to be used by terrorists. Taliban fighters and Al Qaeda terrorists frequented a Soviet era "weapons dump" just North of the Afghanistan border; it is not known if any biological weapons were included amongst the other weapons acquired there
d) Soviet smallpox epidemiologists, who had betrayed many of us in the World Health Organization by lifting smallpox scabs from patients in India and elsewhere, and then smuggling these infectious specimens back to Russia to become part of Vector's "collection" used to create the infamous India-1 "weaponized smallpox" fell on hard times after the breakup of the Soviet Union. So did some of the virologists at Vector who worked on weaponizing smallpox and other biologicals; there is evidence some of these scientists visited Iraq, and were paid to consult with colleagues in Saddam Hussein's government on biologicals. There has recently been an active US program to find other work for these scientists to rid them of the financial necessity of such activities. There is even the suggestion, strongly denied by her Russian colleagues, that the eminent smallpox virologist Dr. Nelja N. Maltseva, might have visited or even collaborated with the Iraqis (see Judith Miller's article below).
As for Gating Item #3, no one knows. Preston and Tucker talk about well known Australian experiments altering a gene in mousepox and suggest it would be easy for terrorists---or even college microbiology students who had access to pox----to create a "superpox" impervious to today's vaccines. I won't go into the details but the bottom line is that if anyone had enough hatred and enough money, the creation of a vaccine-proof smallpox variant is well within the realm of the possible. Obviously, if the terrorists have vaccine-proof smallpox, it is silly to vaccinate anyone with a high risk vaccine that is impotent against genetically altered smallpox. David Rosner, of Columbia's School of Public Health, explores this subject below.
How great is the risk of adverse reactions? Again, no one can really quantify it because much has changed, for better and for worse, since the1970's from which the last large datasets are available. At that time the death rate from vaccine was about 2 or 3 per million vaccinated, and the risk of serious side effects about ten times higher. There are factors today which might raise or lower the rate of complications. Thirty years ago far fewer Americans had immune systems compromised by chemo-therapy or AIDs, and the prevalence rates of eczema, a serious contra-indication to smallpox vaccine, were lower as well. On the other hand, recent data from Israel and from vaccination in the US military suggests that vaccinating young healthy pre-screened men and women carries very few risks of side effects and today's ICU medical care for vaccine complications is likely to markedly reduce fatalities. All in all, it is likely that ten to one hundred people per million vaccinated from the general public would have a very serious reaction or even death from the vaccine---somewhere between 3000 and 30,000.
Attached to this email are some of the most cogent writings about smallpox, and about the dilemma of smallpox, that I've read in recent days. They include:
David Rosner's excellent article "The Problem with Smallpox". Rosen teaches public health at Columbia. I don't know where this was published, but it was circulated in emails by Paul Ehrlich of Stanford and I found a copy of it at: http://www.nationinstitute.org/tomdispatch/index.mhtml?pid=224.
Michiko Kakutani's review of Richard Preston's book: "Demon in the Freezer". This is the best single read on the complicated subject of smallpox as a weapon of bio-terrorism. As Kakutani points out, "Demon in the Freezer" will give you nightmares. As grateful as I am for the kind things Preston said about me (and Richard reads these Boffas) I think he errs on the sensational side of the story, not the objective risk assessment that we need today. Of course, objective risk assessment is not the story teller's job, it is the Administration's job, isn't it? And the lack of objective risk assessment by the Administration, is one of the things about all of this that is so troubling.
A Christmas day editorial in the Chicago Tribune, in support of Bush's smallpox plan. Intelligently written, this editorial stresses the difficult message that it feels the Administration is trying to get across: the risk of smallpox is "important" but not "urgent or immediate".
My dear friend Stan Foster's (ex CDC, ex WHO Smallpox Program) thought provoking letter to the editor of the NY Times about the risk of an invasion of Iraq spreading, not quelling, the danger of smallpox...
Judith Miller's NY Times article "C.I.A. Hunts Iraq Tie to Soviet Smallpox" detailing concerns about the possibility that Russian "weaponized smallpox" got to Iraq
And so, here we are, faced with the need to decide whether to vaccinate our families --it is a much different mental exercise than the mathematical teaser faced by the Farmer and his charges by the river . We will each need to make personal decisions under conditions of uncertainty.
Here is why I chose not to vaccinate my family:
To the best of my knowledge, there is no proof of any link between the experiments at Vector and either Al Qaeda or Saddam Hussein, but concern is understandable. If any proof of linkage arises, I might change my mind.
If Saddam Hussein has smallpox, I believe he might well be crazy or desperate enough to use it as a "doomsday weapon" if he were about to be destroyed; but it is also likely that Iraqi scientists have the ability to genetically alter the virus to make it vaccine-proof. If it is an end game, why we he use a virus that we have a vaccine against? It makes no sense.
If Al-Qaeda has the smallpox virus, I do not believe they would be willing to use it. Unlike Saddam Hussein, Al-Qaeda seeks the victory of an entire people, a culture, a religion---not the hegemony of any individual. Smallpox is the ultimate boomerang weapon. If it is released from its captivity at Chicago O'Hare airport, it is only a matter of days before it infects Mecca and Medina. It is not a likely weapon for a war that is a "Clash of Civilizations" unless a combatant sought the destruction of both civilizations.
Smallpox can be prevented if an exposed person is vaccinated as late as four or five days after exposure. While there is some risk that smallpox could be spread unseen for the first attack, within two weeks cases would start to appear and for nearly all Americans, there would be ample time and ample vaccine to be vaccinated after the first attack and still be safe.
I do not want to go into the fear that a small minority of Americans have that the Bush administration is prone to exaggerate the risks of terrorism in general and smallpox in particular as part of an attempt to frighten the public into accepting the erosion of civil liberties. As horrible as that allegation is, I simply have no information on which to make any comment other than to note the fear exists. And for my purposes here, it really does not matter. Based on the evidence I have seen to date, the risk of getting a case of vaccine-preventable smallpox today is just not as high as the risk of an adverse reaction to the smallpox vaccine.
That is the conclusion that I have reached as of today. And unless or until that changes, I will not vaccinate my family and the ones that I love.