Updating the Smallpox Vaccine

14 January 2000
Source: Hardcopy The New Yorker, January 17, 2000, p. 27. Thanks to Richard Preston and The New Yorker.

DEPT OF AMPLIFICATION

Updating the smallpox vaccine.

RICHARD PRESTON

A REALLY big act of bioterrorism has never occurred, as far as anyone knows, although the F.B.I. recorded more than thirty threats or attempts at bioterror during just the first week of January this year. One can only assume that sooner or later some terrorist will succeed, and an infectious organism will be deliberately released on a large population. The most dangerous bioweapon on the planet is Variola major, a form of the smallpox virus. Smallpox mirrors the Black Death of the Middle Ages in its virulence and contagiousness. During the nineteen-seventies, it was eradicated as a disease that circulates in the human population, and officially it exists only in two laboratory freezers, one in the United States and one in Russia. Unofficially, illicit stocks are almost certainly being kept in several other countries, including Iraq and North Korea. There is a vaccine for smallpox, but the World Health Organization keeps only about one dose on hand for every twelve thousand people on earth. In any case, the vaccine wears off: most people today could catch smallpox easily, even if they were vaccinated in the past. The consequences of a bioterrorist act involving smallpox would be devastating.

Efforts to create a meaningful stockpile of smallpox vaccine in the United States, as described in this magazine last summer ("The Demon in the Freezer," July 12th), were going nowhere for a long time. The process was mired in interagency rivalries and the different agendas of military and civilian planners. But late last August, Jeffrey Koplan, the new director of the Centers for Disease Control and Prevention in Atlanta, decided to put an end to the bureaucratic fumbling. He called a meeting of the main players from the Pentagon, the White House, the Food and Drug Administration, the National Institutes of Health, and the Department of Health and Human Services. Some two dozen officials flew to Atlanta and gathered around a long table in a room near Koplan's office. One participant, who took notes, said that after the door was closed, Jeff Koplan made it clear -- very calmly and politely -- that no one would be allowed to leave the room until there was a plan for creating an adequate stockpile of smallpox vaccine. "I want to know the plan for next week and for next month. I want to see timetables. When are you going to get this done?" he said. The meeting wouldn't end until everyone in the room was in agreement.

JEFF KOPLAN is a thin man in his mid-fifties, with sparse blond-gray hair, wire-rimmed glasses, and pale-blue eyes. He dresses in gray suits and colorless ties, but he listens to rock and roll, bluegrass, and the blues, and he once played the mandolin. Koplan is one of the very few doctors in the world who have had hands-on experience managing patients who are dying of smallpox.

Koplan encountered smallpox in 1973. He had just finished his medical residency, and had joined the C.D.C. as an officer in the Epidemic Intelligence Service. He was sent to Bangladesh during the world's last outbreaks of Variola major. At the time, Koplan had a beard, and hair down to his shoulders, and he brought along Grateful Dead tapes to listen to in Bangladesh. He set up a ward in the Infectious Disease Hospital in Dacca, took a crash course in the Bengali language, and hired a man to buy food for the patients, since the hospital didn't supply any. He learned how to diagnose smallpox with his fingertips. "A blind person can diagnose smallpox from the feel of the lesions," he says. "Smallpox lesions have a velvety feel. While they look like bubbles on top of the skin, they feel much more deep-seated." Koplan found that nothing he did could change the outcome of the disease. Twenty-six years later, he did not want to have to manage an outbreak of smallpox in the American population.

The meeting Koplan called in August was extraordinary. Such meetings almost never occur in the federal government, where agencies guard their terrain, and where multi-agency decisions are made in tiny increments through negotiations among policymakers. Koplan refused to comment about the meeting to me, even off the record.

The meeting lasted for many hours, and when it was over the representatives from the F.D.A. had agreed to a number of steps that would allow more rapid testing and licensing of the vaccine. The C.D.C. said it would take over management of the actual creation of the stockpile and would line up a biotech company to manufacture the vaccine. In perhaps three years' time -- although there are no guarantees that this will occur -- we could have a vaccine ready for mass production and stockpiling. It could not be used for routine, large-scale vaccinations like those that took place in the past, since the vaccine could make some people sick -- people whose immune systems have been compromised by chemotherapy, or H.I.V., or an organ transplant. But the F.D.A. would release the vaccine in a national emergency.

A national stockpile of smallpox vaccine is more than just a prophylactic against disease; it would also provide a deterrent to terrorists, who probably would not choose to use a weapon that creates few casualties. And if there was extra production capacity for the vaccine, the United States would be in a position to whip out millions of doses for any other country that was threatened. This could effectively remove smallpox from the military arsenal of Saddam Hussein in a nonviolent way.

Jeff Koplan managed to affect public-health policy and national defense in a profound way in a matter of hours, but the moment was, for him, tinged with a sense of failure. "It's almost inconceivable that the incredible international human effort that went into eradicating smallpox could be overturned by malicious human acts," he says. "People subsumed all their differences working side by side to eradicate smallpox -- Russians, Americans, Brazilians, Indians. In East Africa, wars were literally put on hold, and truces held, while everyone went into the field to get this done. It's such a painful thing to consider that someone could use smallpox for a negative purpose, particularly when you are aware that it could cause hundreds of millions of deaths."

I asked someone who had been at the August meeting if people were mad at Koplan for locking them into that room in Atlanta.

"I had a feeling they were grateful," he said.