There are a lot of reasons I never signed up to be a soldier. I like group decision-making and being awakened gently in the morning, and I am such a lightweight that a battalion of me’s could be overrun by a determined platoon of purse-swinging grannies. The closest I ever got to the military was registering for the draft near the end of the Vietnam War. Now, at 46, I figure if cute, young women aren’t looking for me anymore, neither should Uncle Sam.

Wrong, about Uncle Sam, anyway. A few months ago my president, George W. Bush, called on me as one

of 500,000 “front-line health care workers” – emergency department staff, paramedics, public health nurses, etc. – to step up in the war on terrorism and be one of the country’s front-line soldiers against the threat of a smallpox attack on the American homeland. Instead of Humvees with cannons and other cool boy-toys that the real soldiers get, Uncle Sam wants to arm America’s health care army with immunological Kevlar – the smallpox vaccine. Then those smallpox-immune “smallpox soldiers” can protect the rest of you if terrorists send smallpox into our midst.

I want to be a good soldier, to do my duty as the president has requested and get my vaccine. My vaccine site is quivering at the thought, however, and before I get vaccinated I have this vague feeling I should ask my mom if she thinks it is safe. The smallpox vaccine, you see, is a weapon that occasionally backfires. If all 10 million health care workers are ultimately vaccinated against smallpox, 10 to 20 might be killed by vaccine side effects. Another 300 to 500 will develop serious, potentially life-threatening complications. Some of those vaccinated might pass potentially dangerous infections on to family

members or patients.

At 30 to 50 chances in a million I know my risk of being seriously harmed by the smallpox vaccine is probably less than my chance of being injured in Dunkin’ Donuts by a falling pile of Munchkins. So why not just suck it up and get the vaccine? The answer is not simply one of being a smallpox weenie. It comes, instead and primarily, from being a doctor smallpox weenie, because doctors have been trained for years that no one should get a vaccine that does not have a clinical benefit substantially greater than the risk of vaccine side effects. And there is the rub; the smallpox vaccination just does not cut it when it comes to a doctor’s usual risk-benefit analysis.

There has not been a smallpox case in the world in 40 years, and the likelihood of another smallpox plague remains the stuff of fearful speculation that some terrorist somewhere will get his evil hands on stolen smallpox. Against that improbable risk is the likelihood the smallpox vaccine will harm more Americans in the next year than the smallpox disease itself. That is why as a medical

decision, widespread vaccination of American health care workers at this time makes little sense.

As a tactical decision in a war,

however, it may make more sense, because smallpox is not just another biological cluster bomb. Smallpox has a history as a deadly plague, and as a deadly weapon. In the 50 years after the Spanish Conquistadors invaded Mexico the smallpox they brought with them killed millions more Aztecs than Spanish swords. Centuries ago legend has it that the Tartar hordes were so decimated by a smallpox epidemic they had to give up their siege of the Crimean city of Kaffa. They left with a smallpox sayonara, however; using catapults, they flung smallpox-infected corpses of their comrades over the defending walls into the city below, infecting its inhabitants with smallpox and

giving new meaning to the term “parting shot.”

If you are an enemy intent on harming Americans, smallpox is a potential biological 9-11. It is deadly, scary stuff, killing up to 80 percent of those infected, and is a disease for which there is no treatment. The threat of smallpox here means our ocean frontiers do not protect our homeland and our homes from the “war on terrorism,” a chilling change for a country used to fighting its battles in the homelands of others. It means a nightmarish plague that ravaged our ancestors and still stirs the most elemental fears of the human race might once again be visited on this earth.

Smallpox as a terrorist weapon calls for a different risk-benefit analysis of the smallpox vaccine than most physicians are familiar with, one more familiar to real soldiers. The vaccine is not about disease prevention; it is about preparing for battle and winning a war. Most doctors and other health care professionals will ultimately shoulder the vaccine as a defensive weapon to be reluctantly carried into a battle they never planned to fight because it will help immunize this wary nation against the disease of fear. That is the benefit probably worth the risk

of vaccine side effects.

Smallpox and other terrorist weapons in our homeland mean that to some extent or another, we are all going to be soldiers in this war on terrorism, whether we want to be or not. When America’s health care workers get the smallpox vaccine, as most of us ultimately will, we should pray it is as close to real soldiering as most of us will ever get.

Erik Steele, D.O. is a physician in Bangor, an administrator at Eastern Maine Medical Center, and is on the staff of several hospital emergency rooms in the region.