Mason added, “The variola major virus is also very dangerous–historically a thirty percent death rate. Those who contract the even more serious black-pox form of it remain conscious in a semi-paralyzed state while they hemorrhage and bleed quarts of blood. They feel as though their insides are coming apart before they meet a certain death.” The others at the table stared off into space in horror, trying to comprehend the lethal effects of a disease eradicated decades ago. “Not a pleasant way to go, I promise you, so it’s imperative we act right away.”
Decker asked, “What’s the plan of attack?”
Knapp leaned forward and tapped his pen on the victims’ information sheet in front of him. “Since antibiotics are useless against viruses, we’ve only got two weapons at our disposal: quarantine and immunization. And, as a first step, immediate quarantine for infected persons is a no-brainer.”
“Now wait a minute,” Lofton said. “Let’s not forget, anytime we do that it’s a restraint on personal liberty we have to consider. What’s to prevent healthy citizens from being quarantined among the sick, for example? Plus, this sort of police power was originally meant to be implemented at the state and local level, not federal.”
“I still think the risk of not doing it outweighs any vague and probably unenforceable common law considerations,” Knapp said.
“This is hindsight, of course, but when did we stop mandatory immunization of children for smallpox in the first place, and why?”
Silverthorn explained, “Routine vaccination of the American public stopped over forty years ago after it was declared eradicated. Only scientists, a few military, and certain medical personnel working with the virus got it after that.”
Knapp continued, “Large-scale immunization will not only help prevent the uninfected from contracting the disease but also lessen the severity in those recently infected. Although, admittedly, a broadly-applied procedure like this is not without risk.”
“Such as?”
Chief Corso said, “The New York Department of Health estimates that for every one million people vaccinated, one or two will die, roughly fifteen to fifty will experience life-threatening reactions, and about a thousand will experience other serious reactions.”
“Right,” Knapp said. “Add to that the financial and logistical costs involved, and it becomes a challenging task convincing everyone it’s necessary. Some will certainly argue against it, but we have no choice. The alternative is too terrible to imagine.”
“Let’s also not forget about the antivirals being developed as we speak, which could possibly be administered after infection in combination with the smallpox vaccine,” Draper added.
“Not easily though,” Knapp countered. “We haven’t yet gotten FDA approval for those drugs, so we’d have to expedite the process before we could even consider using them.”
“I promise you, it could be done in days, maybe hours, under these circumstances,” Decker said.
Knapp nodded and looked over at Beverly Mason. “Assuming we go ahead with mass immunizations, how do we manage it?”
“CDC has always favored a ‘ring’ strategy: we start with those we know are infected and work outward in concentric rings. Healthcare teams first immunize individuals who’ve been in contact with confirmed smallpox patients. After that, we get those who’ve been in contact with people in the first round of vaccinations, and so on. With that strategy we hope rapid contagion will be at least curtailed and possibly even halted.”
Health and Human Services’ Harriet Abbott said, “With the cases we have now, we’d need several ring strategies in place, since the outbreak isn’t limited to a single geographical area.”
Michael Knapp agreed and said, “We have enough smallpox vaccine for everyone in the US right now, so why wait to see if the ring strategy works? Why not immunize everyone as soon and as fast as possible, starting with healthcare workers and first responders in any city with confirmed cases of smallpox? They could then help immunize others.”
“I disagree,” Dr. Mason said. “It takes a lot of people to do all these immunizations at once. I still suggest we prioritize using the ring strategy.”
“And I’d push for turning one hospital in each city affected into strictly a smallpox hospital–New York’s Lenox Hill, for example,” Senator Lofton said.
Corso added, “Which would make it much more effective–a central location with isolation areas staffed by vaccinated personnel.”
“I don’t see how that’s possible,” Walters said. “It’s not like those hospitals are sitting there empty, and we can fill them up with strictly smallpox patients. We’d be taking away resources from other patients who need them.”
“And, if we do that, whatever hospital we use needs to have a negative air pressure room,” Dr. Silverthorn pointed out. “Which not all hospitals have.”
“Why not just treat them at home and keep them out of the general population?” Decker asked.
Mason shook her head. “Still too many chances of infection–to both patient and those around her. Best care for smallpox patients is at a hospital where they’d be treated and quarantined properly.”
“What about those who refuse to get the vaccine?”
“Then make it mandatory,” the vice president said.
Knapp disagreed. “With all due respect, sir, that could make things worse. We’d have people who’d head for the nearest train station, airport, or highway and hightail it the hell out of town to get away from the threat. The result being, they’d end up infecting more persons elsewhere.”
Silverthorn added, “They’d also end up in places where they don’t have healthcare professionals who’d recognize the virus. At CDC we worry they’d send infectious persons back to their homes and families, or to places that don’t have adequate lab facilities or resources to deal with the infection.”
“Then why not just ban all travel?” Decker asked.
“We can’t do that, either,” Knapp said. “It’s drastic enough to be unworkable and should only be considered if we get to the second or third wave of infection and things are getting out of control. Though I agree, travel by known contacts should be prohibited.”
“A total ban would be impossible to enforce,” Wall said, “besides being devastating to the economy.”
“It may be out of our hands by then anyway,” Abbott said. “Many will try to flee those cities where cases are popping up. New York’s governor, for example, has already said he’s prepared to restrict nonessential travel within his state. Other governors will surely do the same. I expect Mexico and Canada will at least close their borders if the outbreak worsens.”
Dr. Mason said, “Let’s consider another theory. By the time our smallpox victims reach the infectious stage, they’d likely be too sick to wander around spreading the virus, so it may not be as bad as we expect. We’d still have time to immunize those with whom they’d come in contact before we got past the second wave.”
“Which is when, relative to when they become contagious?” Decker asked.
“Exposure to the virus is followed by an incubation period of twelve to fourteen days,” Mason said, “during which they are not contagious. They become contagious at first sign of symptoms–fever, body aches, sometimes vomiting–and remain so until all the scabs have fallen off.”
“So a smallpox patient’s contagious period is roughly three weeks long, starting twelve to fourteen days after first exposure to the virus. Which means those two patients together in Hawaii were infected by a common carrier, not from the other.”
“Correct, which is usually the case”
Dr. Silverthorn added, “If they’d been immunized within three days of exposure, they’d be home free. But most people wouldn’t know they had the virus until symptoms started to appear–and by then it’d likely be too late.”
The assembled group understood the danger the country faced and spent the next half hour discussing curtailment of travel, as well as regulations concerning who would ha
ve priority once they began a widespread immunization.
Decker turned to the president’s security advisor. “How in hell could this have happened anyway when CDC and all the other geniuses out there assured us smallpox had been eradicated–that it was nothing to worry about?”
Wall shook his head. “Any number of ways. No doubt some of the samples escaped with the collapse of the Soviet Union. Its laboratories were seriously underfunded all along, and security toward the end was careless, to say the least.”
“We think the Russians haven’t been completely upfront about this since then either,” Senator Kraft added. “By international law, samples should have been securely contained only in labs at CDC and the State Research Institute of Virology and Biotechnology in Siberia. We suspect, however, some of those samples disappeared and renegade stocks exist in numerous small labs around the world–countries run by dictators and radical Islamists.”
“I’m sure the CIA would substantiate that,” Lofton said.
“Plus, the virus could have been re-engineered into existence in a sophisticated genetics lab in any number of places. No one wants to admit that scientists who suddenly found themselves out of a job when the Soviet Union fell wouldn’t quickly find work elsewhere–not always with a friendly nation. Saddam, most likely, hired a few; others may have smuggled samples out to make a big score with Syria or Iran. Russian authorities, to this day, have no idea where those scientists went.”
“Hell, they were so screwed up a rogue scientist could have strolled away from a Soviet lab with a master seed strain in his coat pocket, and no one would be the wiser.”
Lofton whispered to Dr. Mason, “Are we sure it didn’t come from CDC? After embarrassing security lapses at your facility a few years back, should we be surprised?”
Mason gave him a dirty look and whispered back, “With all due respect, screw you, Senator.”
“Let’s also not forget our buddy in North Korea,” National Security Advisor Wall added. “Kim Jong-un would gladly have paid a dictator’s fortune for the virus, even if it meant starving his own people. Soviet scientists had plenty of opportunities to keep ampules of the virus and sell him whatever he wanted.”
Kraft nodded. “A list of countries having clandestine stocks of the stuff could be longer than you’d think. China, North Korea, and Iran come to mind immediately.”
Wall pointed to a map of Asia on one of the TV screens. “The spooks at Langley tell us the countries you named and others have ballistic missiles capable of delivering the virus to any number of neighboring countries–Pyongyang to Tokyo, for example–essentially decimating that nation’s population.”
“With worldwide ramifications,” the vice president added.
Wall nodded. “Missile biowarfare is certainly nothing new. A defector told us more than twenty years ago the former Soviet Union had tons of liquid smallpox ready to be loaded aboard missiles aimed at American cities, given the signal. Seems they came up with a warhead cooling system that would preserve the agent, slow its re-entry by parachute, and disperse the agent over a wide area through smaller bomblets in the warhead. Test-launched them at one point with some success.”
“Count North Korea in on it, too,” Kraft said. “Their KN-14 is fully capable of reaching Chicago and other major North American cities with any kind of agent they want.”
The participants agreed to leave it to Homeland Security and the FBI to identify and prosecute persons responsible for releasing the virus. Meanwhile, CDC would head up public health aspects of the contagion, albeit with some jurisdictional overlap–where tissue or blood samples sent to CDC for analysis, as an example, might be needed by the FBI for eventual prosecution. Some suggested that the mayors of New York, Atlanta, Memphis and other cities directly affected coordinate local police and emergency management teams. Governors, meanwhile, would act as spokesmen at the state and local level, serving as singular voices for that particular state’s management of the epidemic.
The assembled panel spent the last few minutes deciding how best to contain the outbreak and minimize both exposure and death. After some initial dissent, they agreed to begin mass immunization in major cities east of the Mississippi plus Hawaii at first sign the ring strategy wasn’t working.
Mason added, “We've got a smallpox outbreak of unknown origin and a potential calamity of unknown proportions. Few people outside the military remain immune to the disease, so if ring containment fails, we'll have no choice but to begin immunizing on a mass scale. Admittedly, it’s a dangerous vaccine, and some of our citizens will be harmed in the process, but its use is more than justified under the circumstances.”
Assured by Doctors Mason and Silverthorn there was enough vaccine on hand to inoculate everyone given sufficient time, the group began establishing priorities for immunization. Household members and others who have had face-to-face contact with smallpox patients would be immunized first, followed by persons involved in the medical care or transportation of confirmed or suspected smallpox patients. Next in line would be persons with a high likelihood of being exposed to infected materials, such as those responsible for waste disposal. Others would follow, with priority dependent on extent of the outbreak and their particular situation.
They decided CDC would be responsible for delivering the vaccine, establishing protocol at applicable hospitals and laboratories, mobilizing personnel to assist state and local officials with investigations, technical assistance, immunization strategy, and providing recommendations regarding quarantines. State and local public health officials would activate specific emergency response plans and coordinate health teams’ responses to law enforcement agency requests concerning criminal investigations.
“Let’s also not forget about the myriad medical problems we face in carrying out this program,” Dr. Mason added. “Since the incubation period is so long, and the infectious period starts so innocuously, emergency room personnel and clinic staff need to be alert to a potential case of smallpox in every instance. We don’t want a repeat of the Ebola fiasco of a few years back.”
“One note of caution,” Deputy Chief of Staff Draper pointed out. “A lot of people will go to work even when they don’t feel well. You know how it goes: no work, no pay.”
McGraw added, “Street criminals won’t cooperate, either. That’ll be obvious. Drug dealers aren’t going to stay home, even if infected.”
Knapp added, “So much, too, depends on how many people our infected person comes in contact with. Did he ride in a crowded subway? Visit a busy emergency room? Work ‘til he was too sick to stand?”
Rusty Draper nodded. “And what really concerns the president is how to handle information released to the public. In this Internet and rumor-crazy world, there is no way to keep a smallpox outbreak secret for long.”
“Of course not,” Abbott said. “Reporters will demand answers; citizens will see first responders showing up in biohazard suits and panic; the media will under-report the extent of the contagion or exaggerate talk of quarantine. Everyone with a sniffle will rush to an emergency room. It’s inevitable.”
“Which is why it’ll be important to give one consistent message of confidence, efficiency, and professionalism,” Draper said. “We also need to decide how to handle the issue of terrorism. We know what we’ve got, but what do we tell the public?”
“It’s a tough call,” Corso said.
FBI’s counter-terrorism representative McGraw said, “There’s no question this was a terrorist attack, and I’m confident we’ll find those involved and bring them to justice. But since they’ve hit us hard this time, they could strike again–and soon. A follow-up attack while still reeling from this one would be a logical response in the mind of a terrorist. We’ve got to be prepared for that.”
Several participants nodded, although no one spoke for the next few moments. Finally, the vice president broke the silence. “President McHugh will be back in DC in two days. We’ll be speaking to him in the next few hours about wha
t we’ve discussed here.” He nodded toward Deputy Chief of Staff Draper. “Once he’s had a chance to assess the situation, he’ll decide at that point whether to go ahead with his plans to go to Hawaii for the Far East Summit or stay home. In the meantime, I’m to be kept in the loop on every major decision in this matter.”
16
Tom Shannon looked up from his newspaper as Marchetti walked into the hotel restaurant and sat down across from him. “You’re up early,” Tom said.
Marchetti shrugged. “Didn’t sleep well.”
“A lot on your mind?”
Marchetti nodded. “Yeah, this Gautreaux guy. Still bothers me how he knew we’d be on that flight”
“I’m betting you or Vicki were bugged, either at your home or office.” Tom folded his newspaper and put it to the side. “I’ve found out a few things about him, though.”
“Such as?”
“While you were at the hospital last night, I dropped in on Sergeant Kalani and introduced myself. He was duty officer but was willing to talk about the shooting as long as things didn’t get busy, and we didn’t venture into evidentiary matters.”
Marchetti was surprised Kalani would agree to talk with any inactive law enforcement type about a pending investigation, much less someone from off the island. He sounded so accusatory the night of the shooting and the next day in his office, Marchetti figured it would be an ongoing battle to get anything helpful from him. But then a bizarre story about terrorists in Dallas and a shooting on a dark, island highway might have caused anyone to be suspicious. The fact that Tom was a retired homicide detective might account for the difference in Kalani’s level of trust, since cops do tend to stick together.
“They’ve identified the driver,” Tom said and pulled out a scrap of paper from the side pocket of his jeans. He squinted to decipher his handwriting. “Robert Delfino from Port Andrews, here on the island.”
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