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Then came the terrorist attacks of September 11. In November, President George W. Bush made a symbolic visit to the CDC, while the first Smallpox Bio-terrorism Preparedness Meeting was being held. Most of the doctors there were required to be vaccinated against smallpox. I was one of them.

The reappearance of smallpox would be much more than a theoretical exercise for any of us who originally defeated this terrible disease, including my former boss, D.A. Henderson, M.D., who was head of the WHO smallpox eradication program and is now director of the Office of Public Health Preparedness. For us, this is a personal war; we are fighting smallpox once more because human beings may have stolen a live virus and are now planning to let out the evil demon we bottled up two decades ago—or, worse, have created some modern bioengineered hybrid that is vaccine-resistant.

Looking Forward with Hope
In the face of all this danger, is there any hope? The answer is yes. We are much better off now than we were when the Dark Winter was played. Last year, epidemiologists were very concerned to learn that the WHO's vaccine safety net of 200 million doses had been destroyed in the late 1980s when the United States withheld funds and the agency was unable to pay $50,000 to refrigerate the supply. This past summer we thought we had only 15.4 million doses of vaccine, but now we know that soon we will have enough vaccine to protect the country, thanks to two discoveries: first, that our existing vaccine can be diluted to produce five, maybe even ten times as many doses; second, that there's an additional stock we didn't know about. Having enough vaccine, however, does not mean everyone can, or should, get it. Vaccination itself carries substantial risks, including a death rate of up to three per million immunized with the older formulations—a fact that makes us still vulnerable.

But today, the state health departments and the CDC have taken the experience we gained in eradicating smallpox two decades ago and brought it up to date in a careful plan to deal with any outbreak. We will use the same good epidemiological tools: quickly detecting smallpox if and when it occurs, isolating all cases and contacts, and vaccinating anyone who is likely to contract the disease. We eliminated smallpox once. We can do it again. The odds that a terrorist would ever use smallpox against us are very low. But if one does, we will be ready.

Lawrence Brilliant, M.D., author of The Management of Smallpox Eradication in India (University of Michigan), is writing a memoir.

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