An ASA Book Review by:
Professor John Ellis van Courtland Moon

Scourge: The Once and Future Threat of Smallpox
by Jonathan B. Tucker

(NY: Atlantic Monthly Press, 2001)
          At the close of his fine book on one of the most dreaded diseases in human history, Jonathan Tucker of the Washington Office of the Monterey Institute of International Studies warns that the story of smallpox is "as much a cautionary tale as an inspirational one". Dr. Tucker narrates two parallel stories: the world-wide crusade to eradicate this dread disease, and the current threat posed by its possible use by terrorists. Despite the fact that terrorists have so far largely limited themselves to low-tech attacks, the possibility that they could graduate to the use of weapons of mass destruction is too frightening to be ignored.
          The horrific 11 September 2001 attacks on New York and Washington are a clear signal that terrorists have graduated to targeting large population centers and to inflicting massive civilian casualties
          Dr. Tucker writes in clear and forceful language. He shows ability in explaining complex scientific facts in a manner comprehensible to laymen. He also shows an ability to combine concrete, often moving, narration with his considerable analytical skills. This reviewer admits that he now knows more about smallpox than he ever did before. The first chapter introduces the major question in dealing with smallpox: should the remaining acknowledged stocks of the smallpox virus, held at the Centers for Disease Control in Atlanta and in the Vector facility in Siberia, be destroyed or retained? The second and third chapters summarize the past history of smallpox, including its impact on war [for example, the role it played in wiping out Aztec civilization], and the gradual development of counter measures which culminated in the development of Dr. Edward Jenner's vaccine at the close of the 18th century. It is sobering to be reminded that medical and religious leaders often resisted vaccination efforts long after their beneficial effects had been proven.
          Chapter 4-7 narrate the heroic WHO campaign waged to eradicate this frightful scourge from the earth. Although the story has many heroes and heroines, special attention is devoted to the leadership of the epidemiologist D. A. Henderson. Henderson believed that smallpox could be eradicated since it was one of the few diseases that affected only humans. The crusade to eliminate smallpox was carried out under conditions of incredible difficulty: the logistics of carrying the campaign into remote, often hostile, areas; the problem of tracking down infected cases; the difficulties posed by the WHO bureaucracy, many of whose members were skeptical regarding the possibility of achieving eradication and some of whom were outrightly hostile to Dr. Henderson; religious opposition and the preference for superstitious cures among certain tribes and sects. Henderson's strategy was to concentrate successively on certain geographical areas, beginning in Brazil and Indonesia, moving from a campaign in West Africa to the Middle East, then to India, Bangladesh, Pakistan, Ethiopia and finally Somalia. It was a campaign in which success was often followed by setbacks. The traditional approach, herd inoculations, was replaced by a new approach: surveillance containment.
          First, areas where outbreaks of smallpox were occurring were identified, then medical efforts were concentrated on inoculating all those who might have been infected or come into contact with the infected in those areas, thereby taking measures to insure that it did not spread further. Dr. Tucker compares this strategy to building firewalls to contain conflagrations. Despite numerous setbacks and frustrations, the campaign ended in success. In May 1980, WHO official declared that smallpox had been vanquished and the decision was taken to end routine vaccination.
          The Soviet Union had played a major role in the campaign against smallpox. Chapter 8, entitled "The Soviet Betrayal", therefore comes as a shock to readers uninformed of the secret biological warfare [BW] program pursued by the Soviet and later the Russian governments during the decades when the anti-smallpox program was being publicly pursued. The BW program, which included, among other projects, research and development efforts to strengthen the lethality of smallpox, was in flagrant violation of the 1972 Biological and Toxin Weapons Convention, signed and ratified by the Soviet Union as well as the United States. This Soviet effort was undertaken within two organizations: the Ministry of Defense and Biopreparat, a complex of research and production facilities spread throughout the USSR, an empire within the empire. The vastness and the complexity of the Soviet endeavor became known to the Western world through two defectors: Dr. Vladmir Pasechnik, a senior Biopreparat scientist, who defected in 1989 to the United Kingdom and Dr. Kanatjan Alibekov [Ken Alibek], deputy director of Biopreparat, who defected to the United States in 1992. These defectors exposed the duplicity of Soviet conduct. Why did the Soviet Union, and especially its scientists, carried on such a nefarious course of action?
          Jonathan Glover, in his book Humanity, provides the historical answer: nations imitate what they think their opponents are doing. The Soviets fell into "the Hobbesian trap" of mutually reinforcing fear. In this case, the Soviet scientists were spurred by the belief that the US was doing exactly what they themselves were doing: cheating on the Biological and Toxin Weapons Convention by pursuing an advanced secret BW program. The Soviet program, continued under the Gorbachev administration, was only officially discontinued in April 1992 by President Yeltsin.
          The extent of the Soviet "toxic archipelago", to quote Amy Smithson's memorable phrase, that existed under Biopreparat, is now clear. What remains still controversial are the military plans for the use of this vast arsenal. Tucker grimly cites the allegation that several SS-11, SS-13 and SS-17 intercontinental ballistic missiles, armed with biological agents, were deployed near the Arctic Circle aimed at the United States. The envisioned plan was for an apocalyptic war: a nuclear attack followed by a follow-up biological strike. It is worth quoting Dr. Tucker: "Soviet military doctrine for strategic biological warfare called for delivering massive quantities of contagious agents against urban targets to cause panic and social disruption, overwhelm the enemy's medical system, and spawn widespread epidemics that would be impossible to control." Among the agents that would play a key role was the smallpox virus: "Smallpox biological weapons were intended for use against U.S. cities in a war of total mutual annihilation, with the aim of killing the survivors in the aftermath of a nuclear exchange."
          Given the insanity of some the Cold War plans of both antagonists, it is certainly conceivable that such plans were drawn up. However, the former Soviet Ministry of Defense files are still unavailable. Jonathan Tucker presumably got his information, as I did for another study, by interviewing Ken Alibek who never saw these plans. The Soviet system was so highly compartmentalized that it is highly doubtful that the military shared their top plans with Biopreparat officials. We will have to wait until the Soviet military plans are available; if they ever are.
          In Chapters 9-12, Tucker returns to the issue of retention versus destruction of the remaining stocks of the variola virus. The revelations regarding the Soviet program and increasing concerns regarding possible terroristic use of biological weapons challenged the initial WHO decision to destroy the remaining stocks of the variola virus held by Russia and the United States. Moreover, as the Soviet Union disintegrated, serious concerns were raised about the security at the Moscow laboratory where the remaining Soviet variola virus stocks were held. The destruction decision was repeatedly delayed by vote of the World Health Assembly during the 1990s with the final date for destruction being set at 31 December 2002. Meanwhile, the United States was having its own debate, largely between those who wanted to get rid of the stocks and those who wanted to keep them in order to carry out further defensive research. This debate was characterized, not surprisingly, by infighting between and within the agencies of the US government which pitted the Pentagon and the CIA against some major scientists, especially D. A. Henderson, and some members of the National Security Council staff.
          Finally, President Clinton had to cut the Gordian knot. In April 1999, he announced his decision for the retention of the stocks. Unlike many who write on the dangers of terrorist use of biological weapons, Dr. Tucker is a sober scholar who weighs the possibilities carefully and eschews some of the more alarmist analyses. However, in his final chapter, he details at length a bioterrorism exercise held in February 1999 at Arlington, Virginia. The scenario presented on that occasion projected a terrorist release of smallpox in the northeastern United States. It demonstrated fundamental weaknesses in any response to this attack: the delays in correct diagnosis which would inevitably follow the appearance of the first symptoms of the disease, the confused government delay in responding to the crisis, the problems of identifying the victims and the subsequent delays in carrying out vaccinations to contain the spread of the disease. As the disease spread, the vaccine supplies would dwindle and then vanish. If the situation was not placed under control, it would result in a pandemic. No matter how low the probability of a BW attack, the inescapable conclusion is that a thoughtful preparedness program is essential to the defense of the United States.
          Ironically, we can only hope that the terrorist remain addicted to dynamite and to other low tech attacks although the attack launched on 11 September had such devastating consequences. After all, these forms of attack are theatrical, highly visible and immediate in their effects and consequences. But then, we are lead to a further, even more horrifying reflection. A terrorist use of a nuclear device in a major US city would command the same advantages for a terrorist and would be far more devastating than even the attack of 11 September.

Editor's Note: Professor John Ellis van Courtland Moon is Professor Emeritus, Fitchburg State College, Massachusetts USA and a most prominent and respected NBC historian and author. His reviews, reports, articles, and books are noted for their accuracy, clarity and timeliness.