Yale Medicine’s roundtable on bioterrorism was an encouraging take on a very discouraging subject (“Lessons from Anthrax,” Spring 2002). It was particularly heartening because so much care has gone into thinking about how to deal with the possibility of great tragedy.

The big issue that those interviewed skirted, however, was the politics of coercion in public health policy. This is an old issue within public health, certainly. But it becomes much more salient as discussions proceed about mass vaccination for diseases such as smallpox and anthrax, either before or during an epidemic.

Under what circumstances would it be permissible for the federal or state governments to require vaccination for such diseases? Right now, most public health authorities are advocating only “ring vaccination” in case of an outbreak of smallpox. And even Anthony Fauci has eloquently written in a recent issue of The New England Journal of Medicine that the formulation of smallpox vaccination policy must proceed through democratic dialogue.

But how will we balance the often-competing values of democracy and authority, coercion and informed consent, in the midst of a bioterror crisis?

One thing is certain: we need to begin to reflect on these matters now, not during such an episode. The time to begin is now, and our discussions must include ordinary citizens as well as public health elites.

Robert Johnston
Associate professor of history