Future Tense

George W. Bush Set Out to Vaccinate Health Care Workers in Case of a Smallpox Bioattack. It Was a Disaster.

Members of the military got vaccinated too—but they didn’t have a choice.

A collage of torn smallpox vaccine posters
Photo illustration by Slate. Photos by U.S. Army and Getty Images Plus.

As the United States struggles to distribute and administer COVID-19 vaccines, we’re looking back at the history of vaccine rollouts in our country, including the logistical roadblocks to shots and communicating with a fearful public. The COVID vaccines have been widely shown to be safe and effective, unlike some historical examples that had significant associated risks. But what can stories of failures from the past teach us about how to fairly administer them?

On Tuesday, Feb. 16, at 1 p.m. Eastern, join Future Tense for a conversation with Atul Gawande and Helene Gayle, co-chair of the National Academies framework for vaccine distribution, about the COVID-19 vaccine rollout.

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On Dec. 13, 2002, President George W. Bush went on television and announced that military personnel serving in high-risk areas would be getting smallpox shots. Americans were no longer regularly inoculated against variola, a virus the WHO had declared eradicated in 1980, and Bush and his administration were convinced Iraq might use it as a weapon in the coming war. The president told viewers he would get a shot himself, to share risk with the troops. Then, he issued a stern warning: “America has stockpiled enough vaccine and is now prepared to inoculate our entire population in the event of a smallpox attack. Americans and anyone who would think of harming Americans can be certain that we are prepared to respond quickly to a smallpox emergency.”

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Bush’s announcement followed seven months of discussions within his administration about the shape a smallpox vaccination program might take. The goals of the program’s Phase I, as it was announced in late 2002, were to immunize 500,000 military personnel on a mandatory basis and to persuade 500,000 people who would be on the front lines in the case of a bioterror attack—health care workers, public health officials, emergency personnel—to take the vaccine voluntarily. In Phase II, the program intended to vaccinate 10 million more first responders and health care workers over the course of a year. The idea was, in case of an actual smallpox attack, these vaccinated personnel would be able to administer vaccines to others and retain a semblance of social order.

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In the end, the program was a failure—and, given some reports of health care workers’ hesitancy in the course of the COVID vaccine rollout, perhaps an instructive one. By January 2004, 578,286 military personnel had been vaccinated, but only 39,353 health care workers had made the decision to take the shot. Health care workers’ reluctance, fueled by concern over side effects and uncertainty around compensation if anything were to go wrong, drowned out the government’s pleas for nurses, doctors, and staff to get on board. What’s more, after the United States invaded Iraq but failed to turn up any evidence of biological and chemical weapons, what started as personal hesitancy around the shot turned, for some health care workers, into something more like active resistance to the idea of being vaccinated as part of this particular war effort.

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The smallpox shot was a bigger ask for health care workers than other vaccinations might have been. As Anthony Fauci (the man has been around) said in a briefing on the possibility of smallpox vaccination in July 2002, smallpox shots were “probably the least safe human vaccine.” People with eczema and atopic dermatitis could get eczema vaccinatum, a serious (and terrifying) rash that can be fatal if left untreated; pregnant women whose condition slipped through pre-vaccination screenings could suffer the rare complication of fetal vaccinia, which could cause stillbirth; there was the possibility of developing myopericarditis (as some vaccinated service members did) or post-vaccinal encephalitis.

A man gets vaccinated by a health care worker.
Photo courtesy of the Department of Defense, American Forces Information Service, and Defense Visual Information Center
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These concerns were prominent in some health care workers’ decision-making around taking the vaccine. Daniel J. Kuhles and David M. Ackman, then public health officials in Nassau County, New York, wrote in late 2003 in a status report on the vaccination push that the CDC had provided an “elaborate process of screening and informed consent” that was supposed to exclude people at risk of reactions. But that process, they thought, “also dissuaded a large number of people without contraindications who had expressed interest in being vaccinated.” Their local results weren’t encouraging: Of the 95 people the department asked to consider vaccination, just 11 went ahead with it.

There was also some confusion over how vaccinees who experienced adverse reactions might be compensated. People who get the smallpox vaccine can be contagious to others for a period of a few weeks afterward, and Kuhles and Ackman wrote that since state workers’ compensation programs would be responsible, at least in New York, it was unclear whether family members hurt by unintentional spread would also be compensated. This uncertainty, they wrote, “might have created the impression that the government wanted individuals to foot the bill for national bioterrorism preparedness.”

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But more than anything, health care workers were unconvinced that the shot was necessary. Kuhles and Ackman point out that even as these workers were being asked to get vaccinated, “the federal government was offering messages of reassurance to the public,” soothing them by downplaying the risk of a smallpox attack. And then, throughout 2003, as the military failed to turn up the promised stockpiles of biological weapons in Iraq, an attack came to seem less and less likely.

Many nurses initially supported the vaccination program and then turned against it. Nurses, gender studies scholar Gwen D’Arcangelis found in a look back at the profession’s reaction to the vaccination program, were quite worried about they might inadvertently infect a vulnerable patient with smallpox. D’Arcangelis also found evidence that health professionals questioned the very basis for the program, arguing that the predictive modeling used to show the smallpox threat “relied too heavily on worst-case scenarios.”

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The American Nurses Association, state-level nurse associations, and labor unions organized against vaccination. In January 2003, the ANA sent a letter to Bush highlighting their concerns: among others, worries about transmission to patients and family members, questions about who would provide compensation if a vaccinee needed to miss work for an adverse reaction, and the lack of professional protection for any nurse who refused vaccination. Also that month, the Service Employees International Union and the American Federation of State, County, and Municipal Employees called for the government to suspend vaccinations unless the administration would provide medical screening of volunteers and compensation for anyone who had a negative reaction to the vaccine.

The matter of pay for those who experienced adverse reactions became a sticking point. Under the provisions of the Homeland Security Act, such a vaccinee would have to sue the federal government and prove its negligence. “The problem still is,” SEIU president Andrew L. Stern told the Washington Post on Jan. 17, 2003, “if a worker or patient get sick as a result of this vaccine, they’ll be lucky if they receive a get-well card from Washington.” With the passage in April of the Smallpox Emergency Personnel Protection Act of 2003, those who reacted poorly to the vaccine were covered—but for the Bush administration’s program, it was too late.

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Nurses’ associations in Massachusetts and California also opposed the program for political reasons. D’Arcangelis found a newsletter of the Massachusetts Nurses Association from January–February 2003 with a piece titled “Vaccinate Against War, Not Smallpox”:

We say NO not out of fear for our own health. Every day we face the risk of infectious diseases at work. WE have never shied away. We say NO not out of fear of side effects of the vaccine. … We say NO because vaccinating the face of no known threat is wrong. It represents the use of health care as an extension of an aggressive military posture.

For some in the press, the nurses’ refusal became a partisan issue. On Jan. 23, 2003, the Washington Times—then, as now, a right-wing paper—ran an editorial titled “Smallpox Refuseniks,” which scolded health care workers for resisting the program and expressed surprise that the president could not force their cooperation. “While the health professional[s] undoubtedly realize that there’s a war on,” the editorial ran, “they fail to appreciate how grave the smallpox threat is, and will remain, regardless of what happens in Iraq. While their patriotism may be unimpeachable, their judgment is questionable.”

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Surveying the “refuseniks” by telephone in 2003 and 2004, a team led by Pascale M. Wortley found that about half refused because they, personally, had contraindications (like eczema) or worried about affecting somebody in their household who had them. Others were worried about adverse reactions to the vaccine, and 20 percent of that second group believed that the risk of an actual outbreak wasn’t high enough to be worth the potential issues with the shot. “Hispanics, blacks, and Asians,” Wortley and colleagues wrote, “were significantly more likely than whites to be somewhat or very concerned about side effects.” And while surveying physicians at Yale University in February–April 2003, Andrea L. Benin and her co-authors found that only 5 percent had been or intended to be vaccinated. Fifty-five percent believed that the benefits of vaccination did not outweigh the risks, and only 3 percent thought a smallpox attack in the next half-decade was “likely or very likely.”

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It wasn’t only individual employees and their professional associations—some hospitals also threw wrenches into the government’s efforts. Edward P. Richards and co-authors, in a 2004 postmortem analyzing legal aspects of the vaccination drive, found that health care employers realized that vaccinating employees would impose significant administrative burdens and legal risks. They would need to set up surveillance systems to keep track of those who had vaccine sores that could be contagious. They’d have to find out which independent contractors might be at risk for vaccine-related injuries and make sure they signed agreements. “When most health care employers considered the uncertainties in the plan along with the medical and legal risks,” the researchers wrote, “they decided not to participate.”

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In June 2003, the CDC put aside the Phase II plan to expand vaccination after 52 cases of heart inflammation surfaced in vaccinated soldiers and civilians. As the program went out with a whimper, the independent U.S. Institute of Medicine issued a report in August 2003 strongly arguing that the entire thing was a waste of time and money that should have been spent on surveillance and response planning. “There are many things more important than vaccinating people. We have no idea if we’re prepared for a bioterrorist attack,” Brian Strom, lead author of the report, told the New Scientist. Though half a million military personnel were vaccinated, Strom pointed out, there was still no real plan for mobilization in the case of a smallpox attack.

Future Tense is a partnership of Slate, New America, and Arizona State University that examines emerging technologies, public policy, and society.

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