In episode 3 of Bedside Rounds, I talk about the human triumph of small pox vaccination, and discuss the government exercise called Dark Winter which simulated a bioterrorism attack on the United States.
One of the greatest victories of public health – and really, our species — has been the elimination of smallpox, or variola. There is nothing small about the pox – humans have no natural immunity, and the kill rate is estimated at 30%. It is highly virulent. A single patient in Yugoslavia in 1972, where the disease had been eradicated, led to an outbreak of 175 cases and 35 deaths. If you were infected, you might just think you had a bad cold, with a fever, headache, myalgias, backaches, and some GI upset. After a week, though, you’d notice something different – rapidly enalarging red splotches appearing all over the mouth. Soon after, your skin would erupt with macules. Within 36 hours, your body would be completely covered crusty lesions. If you’re lucky, these lesions fill with fluid and become pustules, eventually scabbing over and leaving scars. If you’re unlucky, your start to bleed into the skin and gastrointestinal tract, and eventually all your mucus membranes.
The quest to eliminate this scourge of humanity started with Edward Jenner, who demonstrated that cowpox inoculation protected against smallpox. By the way, he “demonstrated” this by inoculating the 8 year-old son of his gardener with cowpox and then exposing him various items from a small pox hospital – medical ethics were very different in the 18th century. Another fun fact — the cow that provided the coxpox was named Blossom, and her hide now hangs on the wall of St. George’s medical school library, a gift from Dr. Jenner’s family to the hospital where he did his work. Not only do we owe Jenner (and Blossom) for the very first vaccine, we owe him for the name itself. His paper was called “An Inquiry into the Causes and Effects of the Variolae Vaccinae”, the scientific name for cowpox, and the source of our word vaccination.
In any event, soon after Jenner’s vaccine, governments across Europe, and later the world, adopted vaccination programs, and by the early 20th century the disease was a rarity in industrialized nations. In the 1950s and 1960s, governments and multilaterals stepped up the goal of eliminating smallpox with a strategy of both vaccination and isolation. The last case of indigenous smallpox was reported on October 26, 1977, by a hospital cook in Merca, Somalia. The last case of smallpox ever is more of a tragedy – a medical photographer at the University of Birmingham was accidentally exposed presumably through a ventilation system and died, leading to the suicide of the head of the department of microbiology. After this tragedy, all known stockpiles of the virus were destroyed or transferred to one of two WHO reference laboraties – the CDC in Atlanta, GA, and the Vector Institute in Koltsovo, Russia. Since then, governments have dropped their vaccination programs, and debate has continued on whether to destroy these two remaining stocks of smallpox – or at least what were thought to be the last two remaining, until the discovery at 6 vials of smallpox earlier this month.
Which brings us to Dark Winter. I first heard this story when I was a medical student, during our lecture on smallpox – the only 60 minutes I’ve had in my medical career dedicated to a disease that once devastated our species. Dark Winter was essentially a public health and policy role-playing game, sort of like Dungeons and Dragons with much higher stakes. It took place in June of 2001, and was designed to test the United States’ capacity to respond to a smallpox outbreak. The following are excerpts from the Infectious Disease Society of America’s comprehensive report on the project:
“The year is 2002. The Unites States economy is strong. Tensions between Taiwan and the People’s Republic of China are high. A suspected lieutenant of Osama bin Laden has recently been arrested in Russia in a sting operation while attempting to purchase 50 kg of plutonium and biological pathogens that had been weaponized by the former Soviet Union. The United Nation’s sanctions against Iraq are no longer in effect, and Iraq is suspected of reconstituting its biological weapons program. In the past 48 h, Iraqi forces have moved into offensive positions along the Kuwaiti border. In response, the United States is moving an additional aircraft carrier battle group to the Persian Gulf.
December 9, 2002
The National Security Council, comprised of the President and his top advisers, meets to address the rising tensions in the South China Sea. That issue is quickly brushed aside with the news that 20 cases of smallpox have been identified in Oklahoma, with 14 more suspected cases in that state, Georgia, and Pennsylvania. The security council quickly reviews the United States vaccine stores – 15.4 million doses, but probably only around 12 million usable ones. The council decides to opt for a ring vaccination policy – enough vaccine is shipped off to the three affected states of vaccinate close patient contacts and essential personnel such as healthcare providers and public safety officers, with 2.5 million doses kept for the military. Some vaccine is kept in stockpile in case the crisis spreads. An additional carrier group is diverted to the Persian gulf. The NSC decides to quickly hold a press conference and inform the public of its decisions.
December 15, 2002
2000 cases of smallpox have now been reported in 15 states, with 300 deaths. The epidemic has crossed borders, with isolated cases in Mexico, Canada, and the UK. All cases so far appear to be related to exposures in three shopping malls on December first. Only 1.25 million doses of the vaccine remain, and the governments of Canada and Mexico are requesting doses. Vaccine distribution has been chaotic and occasionally violent, and many local health care systems have been overwhelmed. The military is expressing concern about getting involved in vaccine distribution, given the evolving crisis in the Persian Gulf. Several international borders have been closed to US trade. Food shortages are popping up in affected states. Schools have been closed across the nation. Public gatherings are limited in affected states. Still, there is no information about who might have attacked the country, but given 24-hour cable news coverage and the swirl of rumors about the disease, violence has been reported against citizens of Arab descent. US drug companies are producing vaccine as quickly as they can, and can make 6 million doses a month, but the first delivery is five weeks away. In the meantime, Russia offers 4 million doses from its stockpiles.
December 22, 2002
16,000 cases have now been reported (14,000 within the last day, showing the exponential spread of the disease). 1,000 people are dead. 10 other countries are reporting outbreaks of their own; it is unclear whether this is from spread from the US or separate attacks. No doses of vaccine remain, and it is four weeks until others will be available. Canada and Mexico have closed their borders. Some states have begun to forcibly isolate victims. Food shortages are growing more extreme. Residents are fleeing cities when new cases emerge. The National Security Council asks for predictions about the spread of the illness – 17,000 cases are expected to emerge in the next 12 days, expected to bring 10,000 deaths, after which hopefully isolation and new vaccine production will help stem the disease. However, worst case scenario projections predict a third-generation of infections leading to 300,000 new cases with 100,000 deaths, with fourth generation infections potentially leading to 1,000,000 deaths.
The scenario ends as the NYT, Washington Post, and USA Today report all receiving an anonymous letter demanding US troops leaving Saudi Arabia, and removal of all warships from the Persian Gulf. The letter includes the genetic fingerprint of the smallpox strain, demonstrating credibility.
When Dark Winter was run, a bioterrorism attack on a large scale was still speculative. Since then, the US has witnessed attacks of anthrax through the US postal system. The discovery of smallpox at the NIH proves that there is still virus unaccounted for. The IDSA in particular points to the former Soviet Union, which maintained 20 tons of smallpox as part of its biological weapons program throughout the 1970s, and apparently by 1990 had a plant capable of producing 80-100 tons of smallpox per year.
The story of the eradication of smallpox is one of humanity’s greatest achievements. The all-too-real story of Dark Winter is the counter to that cheery view of humanity, that even in our greatest success lies the potential for destruction.