"We may have forgotten, but smallpox was, or is, a terrible, virulent disease. It kills one out of every three of its victums. There is no cure. The vaccine effectively immunizes against smallpox, but that protection has a price. Some die from it, and others have serious bad reactions, some permanent. Scientists say it's the most dangerous vaccine known to man. It could protect Americans from the unthinkable destruction of a smallpox attack, but make no mistake, it is a vaccine with a dark side." --Dan Rather, 60 Minutes, "Most Dangerous Vaccine (Smallpox)"

In 2002, President Bush presented a smallpox vaccination plan, focusing first on medical personnel and emergency workers and offering the vaccine on a voluntary basis to the general public later on. Professor of vaccinology Dr. Paul Offit views the vaccine as more deadly than useful, stating "if we immunize a million people then there will be 15 people that will suffer a severe, permanent adverse outcome and one person who may die." He warns that the smallpox vaccine was made over 200 years ago, when vaccine standards were not up to modern standards, with side effects that modern medicine would find unacceptable. Richard Preston, author of "The Demon in the Freezer", worries about the weaponization of smallpox, claiming "smallpox as a weapon is the biological equivalent of the nuclear bomb."

Doctor Paul Offit

2011 photo of Dr. Paul Offit taken by Michael Spencer for the National Institutes of Health Record

Biological safety cabinet

A 2016 photo of a biosafety cabinet, used to safely interact with objects contaminated by dangerous pathogens

Dr. Offit stated that doctors know how to contain smallpox and that there is a safer approach to the fear of a weaponized version of smallpox: making the vaccine, understanding who's going to get it, who's going to be giving the vaccine, and then waiting for there to be case of smallpox. Then, officials can move in quickly to contain the virus by vaccinating people in large numbers. Richard Preston still fears that while doctors do not believe smallpox is a real problem and can be handled easily, the people who weaponized the virus do take it seriously.

Dr. Frieden, the former New York City health commissioner, stated that everyone should err on the side of caution, and in the case of a smallpox outbreak, the general public would not be the first ones to be vaccinated, rather the ones who would be responding to and treating the initial cases would be vaccinated. An addtional factor in vaccinating the general public is establishing who shouldn't be vaccinated: those who have a weakened immune system, such as those with HIV/AIDS, cancer patients, and those who have a transplant, along with people with the skin condition eczema, pregnant women, and infants. 

In the end, it comes down to a question of odds. No one knows the actual chance of an outbreak caused by a bioterror attack. Even then, while the general public havne't been thinking about smallpox, the government has, and is prepared to vaccinate in worst case scenario.