Why Were Doctors Afraid to Treat Rebecca McLester?

The pediatrics ward at SwedishAmerican Hospital in Rockford, Ill., was busy last June 20, its 10 or so patients suffering from the usual ailments of the young. Linda Wildey, the director of women and children's services at the hospital, was looking forward to the end of her workweek when she received a visit from the manager of the hospital's pediatrics department. A 10-year-old girl was heading for SwedishAmerican's emergency room, and she was suspected of having monkeypox. 

''Monkeypox,'' Wildey recalled during an interview in March. ''I could hardly believe I was hearing the words 'Rockford' and 'monkeypox' in the same sentence. It was'' -- she fumbled for a moment -- ''it was shocking.'' Wildey's understanding of the disease was limited. She knew only that it was contagious and that it was nasty. More dismaying was that she and the hospital's chief medical officer, Dr. Kathleen Kelly, slowly realized that finding someone in the pediatrics department to treat the girl was going to be difficult. The small nursing staff could ill afford to dedicate someone full time to caring for the child -- as would be necessary for quarantine. The bigger problem, however, was that none of the nurses, including Wildey, had a recent smallpox vaccination, which was recommended for safe treatment of monkeypox. The more they talked, the more resigned Wildey became. At last, she took a deep breath, sighed and told Kelly that, as head of the unit, she'd agree to be vaccinated that afternoon, and then, since the shot provided quick immunity, would assume the child's care, single-handedly if need be. ''I couldn't ask anyone else to do it if I wasn't going to step up to the plate with them,'' she told me. ''It's my job.'' But as she set down the phone and squeezed her eyes shut, she grimaced slightly. She later recalled thinking, ''My husband will not be happy.'' 

For the past generation, few doctors and nurses in the Western world have worried much about their profession killing them. But with the appearance of AIDS and SARS, a new medical generation has begun to wrestle with old questions. When an unfamiliar and infectious disease stalks through your city, must you treat the affected patients? What are the consequences if you do? And if you don't? 

Monkeypox, as everyone at SwedishAmerican soon learned, is a close relative of smallpox. Both viruses, part of the orthopox family (which includes camelpox, cowpox and gerbilpox), can cause high fevers and scarring lesions. Both can be lethal. But unlike smallpox, which essentially was eradicated by a global vaccination campaign of the 1960's and 1970's, monkeypox thrives in parts of western and central Africa. It was first isolated in monkeys in the 1950's, which is how it earned its name. Its preferred hosts are squirrels, mice and other small rodents. Occasionally it jumps to man. It can then pass from person to person. Several hundred human cases of monkeypox were identified in Congo in the 1990's. Up to 10 percent of the infected die. But the disease had never been seen outside of Africa. Then last spring, for the first time in history, it leaped borders, landing in the United States as a hitchhiker in the glands and secretions of one or more Gambian giant pouched rats, 18 of which, shipped to Texas from Ghana, were destined for Phil's Pocket Pets, in suburban Chicago. 

The American market in such exotics is small but growing. It's also insular and unevenly regulated and thrives on the novel. Among aficionados, the 5- to 10-pound Gambian rat has a scruffy chic (unlike in Gambia, where villagers eat them). At Phil's Pocket Pets, the rats settled in next to two recent shipments of prairie dogs. Health authorities say that at least one sick Gambian rat infected Phil's prairie dogs. 

One of the prairie dogs wound up as a pet in the home of Eric and Amy Boonos of Rockford, who already had two. Their 10-year-old daughter, Rebecca, liked to wriggle her fingers through their cage, giggling as the animals licked and nipped. But the new pet soon died. Then the Boonoses learned that sick prairie dogs were associated with monkeypox. Public health officials seized the two remaining pets and found they had monkeypox. They monitored the Boonoses and, by the middle of June, Rebecca developed a spiking fever and was covered with ugly, pus-filled sores. 

That's how monkeypox arrived in Rockford. Over the course of last summer, 72 cases of monkeypox would be suspected in the Midwest, and 37 would be confirmed. 

By the time Rebecca McLester (who bears her mother's maiden name) was on her way to the hospital last June, there was plenty of low-level chatter about the case in the emergency department. The chatter soon rose to a hum. The Health Department had called ahead to alert the hospital to the girl's imminent arrival and to her probable diagnosis. The hospital staff believed, as Kelly later put it, ''that monkeypox could be contagious between people, and that it had a fairly high death rate in Africa.'' 

Rebecca, over the objections of her worried parents, was asked to remain outside the hospital, sitting in a wheelchair in the parking lot as Kelly and her colleagues rushed to secure the E.R. against infection. They prepped a reverse-airflow isolation room, with fans that would suck in air when a door was opened, preventing germs from escaping. Several of the E.R. doctors had smallpox shots before 1972, when routine immunization stopped, but none had a recent booster. This created a problem. Experts with the Centers for Disease Control and Prevention in Atlanta believed that vaccinations from decades ago would provide only limited protection. (Ten of the people who developed monkeypox had childhood smallpox shots.) So Kelly, who was vaccinated more than 30 years before, pulled on a gown, mask, goggles and booties and, along with the emergency-room physician, prepared to see the girl herself. ''I wanted to show the staff that it was probably O.K.,'' she recalled. ''Plus, I was curious. I was thinking, So this is what smallpox looked like.'' Once she had determined firsthand the nature of the case, she would be able to assemble a team to care for the girl. 

The year before, in the wake of 9/11, SwedishAmerican, like many hospitals and medical facilities in the United States, was asked to participate in a bioterrorism-preparedness campaign. Part of the campaign was a national smallpox-vaccination effort meant to ensure that the United States would have plenty of immunized health care workers. These would be the first responders should terrorists release smallpox back into the world. ''When I asked for volunteers, we got close to 150 acceptances,'' Kelly said. She was pleased, although a little surprised. The vaccine can make people feel sick, and the restrictions on those who've just been vaccinated are daunting. You must keep the site of the shot closely covered and have no direct contact with anyone whose immune system is impaired. Kelly heard that the other hospitals in Rockford got far fewer volunteers, a fact whose implications gave her pause: ''I thought, Oh, my gosh, that will make us the institution on the front lines. I wasn't completely sure our medical staff wanted that.'' After screening, about 50 of the doctors and nurses on staff were qualified to be vaccinated. 

Few of these were in pediatrics, however. So after Linda Wildey agreed to be vaccinated, Kelly started looking for a doctor. Rockford has its share of pediatricians, though not all of them had been vaccinated against smallpox. Kelly paged Dr. Michael Anderson, who had. 

He was working that afternoon in the pediatrics department at Crusader Clinic, a community health center not far from SwedishAmerican Hospital, when Kelly phoned. ''I got the shot during the early stages of the Iraq war,'' Anderson told me. ''I thought, If our soldiers were going over, the least I could do was be ready if something happened here at home.'' Kelly asked him to hurry over to the hospital. They had a girl there with monkeypox. 

The word ''pox'' tends to focus the medical mind. Anderson considered for an instant his own daughters, ages 6 and 2. It was most unlikely that he could carry infection home. But it wasn't impossible. They had no immunity against a pox. 

Still, Anderson agreed to get involved with the case. But he saw that his decision did not please his colleagues, who might, as his partners, have been asked to provide care for Rebecca. None of them had been vaccinated. ''My partners told me I had not needed to take the case and I should not have done it without consulting them,'' he remembered. 

The medical director of the clinic, Dr. Bechara Choucair, defended his staff. ''Some providers believed that prior vaccination with the smallpox vaccine is necessary before providing any direct patient care,'' he wrote in a letter sent to me in March. A spokeswoman later pointed out that, strictly speaking, Anderson's partners were not obligated to participate in Rebecca's treatment because she was not a patient of Crusader Clinic, with which they were affiliated. SwedishAmerican would have had its own rotation schedule of doctors. The spokeswoman added that ''the fact that the partners hadn't been vaccinated would have hindered their 

participation.'' The pediatrics partners themselves declined to comment. 

''They were angry,'' Anderson said. He said he believed they were scared. In the end, Anderson and the clinic's director agreed that he'd take a leave to serve full time at SwedishAmerican, staying for as long as the girl remained. 

''It was exciting,'' he said. ''It was a chance to provide care. I naïvely thought that everyone would want to be part of something like that. But I guess not.'' 

For years, the concerns faced by the doctors of Rockford have echoed through the halls of African hospitals, whose personnel are disproportionately beset by Ebola, Lassa fever and other killers. Invariably, only some doctors and nurses will volunteer to care for infected patients. A few of them may die, like Dr. Matthew Lukwiya, who was profiled in this magazine in February 2001. Others will flee. ''If you have an outbreak of, say, Ebola,'' said Dr. Daniel Bausch, an associate professor at Tulane University's School of Public Health and Tropical Medicine and a veteran of many epidemics, ''most of the medical staff heads for the hills. They've noticed that the last two or three people to catch the disease were health care workers, and they decide, quite logically, that it's not worth the risk.'' During an outbreak in 1995, an international team of doctors arrived in Kikwit in Congo to find that Kikwit General Hospital was deserted and silent, except for a half dozen or so patients, including medical staff, lying unattended in a back room, dying of Ebola. 

Monkeypox is not as lethal as Ebola, but the issues, emotions and responses it elicited in Rockford did resemble those of the health care community in Kikwit. ''There's always fear of things you don't understand,'' said Wildey, who forbade her pregnant secretary from having any contact with her after she entered Rebecca's isolation room. Later, on that first Friday night, arriving home after 10 p.m., she was not surprised when her husband suggested they might sleep in separate rooms. By then, she had had her vaccination. The vaccine uses a live poxlike virus called vaccinia to help the body develop immunity against smallpox. It was not very likely that she could transmit the virus to her husband or anyone else, but she understood his concern. ''He didn't want to touch my body,'' she said matter-of-factly, and during the next several days, moving between the hospital and her home, she swapped one isolation unit for another. 

North American doctors are still getting used to the idea that their jobs can be so dangerous. ''Over the years, I've had colleagues die from occupationally acquired hepatitis B,'' said Dr. Lawrence Dean Frenkel, a 60-year-old professor of pediatrics and microbiology at the University of Illinois College of Medicine in Rockford and an academic consultant on the monkeypox case. Each of those colleagues was stuck with a needle or otherwise came into contact with tainted blood. Another physician died of meningitis, caught while she was resuscitating a young child. She breathed into the infected child. The child breathed back. 

Those incidents are rare, though. Only the rise of H.I.V. in the 1980's dented, for a while, most doctors' and nurses' complacency about the safety of their jobs. ''I was an intern at San Francisco General Hospital just before AIDS was identified,'' said Dr. Julie Louise Gerberding, now the director of the Centers for Disease Control and Prevention. ''We'd be staying up all night with these patients who clearly were deathly ill, but we had no idea what was happening. We were sometimes lax about personal safety.'' At the time, she was delighted to have her scrubs splashed with blood: ''It made me look like a real doctor.'' It also gave her hepatitis B, but she recovered. 

Such insouciance disappeared as people came to understand that H.I.V. could be transmitted through body fluids. Doctors started turning away AIDS patients. The situation became acute enough that in 1987 the American Medical Association released a rather magisterial statement:''A physician may not ethically refuse to treat a patient whose condition is within the physician's current realm of competence, solely because the patient is seropositive for H.I.V.'' In other words, buck up, follow the standard precautions and get back to work. 

Shortly after Michael Anderson arrived at SwedishAmerican, Rebecca was moved from the emergency room to the reverse-airflow unit in pediatrics. The room was behind glass doors within a larger room that was once part of the pediatric I.C.U. Now that area was filled with a ghostly lineup of unused metal cribs, the whole place underlighted by a funereal yellow glow. 

Anyone going in to see Rebecca was required to wear a leakproof N-95 respirator mask, a splash guard, a surgical hat, a gown, gloves and booties. In this get-up, faces are obscured. You can't touch skin. Doctors who wear glasses, like Anderson, complain that the masks are so tight that lenses fog up. For Rebecca, it must have felt as if she were being treated by indistinguishable wraiths. 

What motivates one doctor or nurse to volunteer in an outbreak and another to beg off? No one really knows, since epidemics in the West have become so rare. ''Even before a polio vaccine was available, large numbers of health care workers, oblivious to their own safety, would volunteer to care for the polio patients in iron lungs,'' said Dr. Donald A. Henderson, professor of medicine and public health at the Center for Biosecurity at the University of Pittsburgh Medical Center and the man in charge of the global smallpox-eradication campaign. ''I am confident that this same selfless concern for others would prevail today should an epidemic occur.'' 

But when SARS hit in Toronto last year, that's not what happened. ''It was hard at first to find doctors to cover the SARS wards,'' said Dr. Leslie Nickell, a family doctor who assisted the SARS control team. Early in the epidemic, Nickell, who is also an assistant professor of family and community medicine at the University of Toronto, organized a study of the psychological impact the disease was having on the personnel at her hospital, Sunnybrook and Women's College Health Sciences Center, which ultimately admitted 71 SARS patients. Twenty-three of these were health care workers, some from Sunnybrook. The results of her survey, published in the March 2, 2004, issue of The Canadian Medical Association Journal, are disturbing. Of the 2,001 respondents, 65 percent reported significant concerns about their health and that of their families. Almost 30 percent, including 45 percent of the nurses who responded, displayed significant levels of ''emotional distress.'' 

Health care workers disliked wearing the uncomfortable masks and having their temperature taken every morning as they reported to work, though they knew these measures were necessary. Nickell also heard more mundane concerns. ''They said that they couldn't have Easter dinner at home with their families,'' Nickell said, because they were in quarantine or on extra shifts. ''That may sound petty, but it matters. Others said their neighbors didn't want them to visit. They felt stigmatized.'' 

Doctors and nurses with children were particularly affected, according to Nickell, prompting some to question whether they would continue to report to work. ''No one wants to spread disease to their family,'' Nickell said. But microbes don't fight fair. They do follow people home. Some of those who developed SARS in Toronto, as in Hanoi and elsewhere, were the children, parents, siblings or close friends of hospital workers. Not all of them survived. 

Ultimately, though, enough doctors and nurses volunteered in Toronto that the SARS wards could be manned. ''It wasn't a hard choice for me,'' said Nickell, one of those volunteers. ''I don't have children, which helps. I suppose my husband was a little concerned.'' She laughed. ''But I don't think it was about my bringing something home to him as much as it was about my own health and well-being. Still, I was very careful for both our sakes.'' There were bad moments, though. ''I remember one day,'' she said, ''we heard that a third hospital had gone down.'' About that time, across Toronto, many medical facilities were closing their doors because SARS had spread to the staff. ''I was with another worker, and we're there in the hospital's SARS control room,'' Nickell said. ''We look at each other, and we both say, 'O.K., now I'm scared.' '' 

After Rebecca McLester was admitted to SwedishAmerican, her fever rose. Pox sores hurt as they erupt, and they were erupting all over her body, including inside her mouth and throat, on the palms of her hands and the soles of her feet. She couldn't swallow and was having vivid, waking nightmares of choking to death. ''It was the most god-awful thing to watch,'' said Eric Boonos, her stepfather. That first day at SwedishAmerican, Boonos, who is tall, burly and bald, with a bristly, six-inch-long goatee, glowered at Anderson and demanded that he do something. 

But there is no cure for monkeypox. The only treatments are palliative. Anderson gave her morphine and provided her with a suction apparatus to help remove the spit and alleviate her feeling of suffocation. Anderson's wife, Stephanie, a nurse who worked with him at Crusader Clinic, volunteered to join him in treating Rebecca. Ten days earlier, in what strikes her as a strange but stirring coincidence, she'd gotten a smallpox shot, little expecting her immunity to be of use so soon. ''It had seemed like the right thing to do,'' she said of the vaccination. ''I'd wanted to be ready if something dreadful happened.'' She was not anticipating monkeypox. 

Over four days, Stephanie Anderson, Linda Wildey and four other nurses traded nursing shifts, with Michael Anderson as the sole attending physician. (There was a consulting physician as well, a specialist in infectious diseases.) On Rebecca's first day in the hospital, she began to thrash and complain that she couldn't breathe. Fearing that her airway was swelling, Anderson urged that she be transferred to Rockford Memorial hospital, which had a full pediatric I.C.U. There, Rebecca could be put on a ventilator if necessary. He called to make arrangements and was told, to his astonishment, that the appropriate isolation units weren't working. 

Kelly later expressed skepticism about Rockford Memorial's explanations. ''I do know,'' she told me, ''they did not want to take that patient.'' A spokeswoman for Rockford Memorial later said that their two appropriate isolation rooms were having pressure problems, which were repaired after a couple of hours. At that point, the hospital would have been prepared to accept Rebecca, she said. 

But by then, Anderson had reconsidered the transfer. ''Luckily, her airway hadn't swollen after all,'' he told me. ''I think she just misinterpreted not being able to swallow as not being able to breathe. Kids do that.'' He gave her more painkillers and decided that she needed a CAT scan to determine whether an abscess might be blocking her throat. This required inserting a special, thick IV line to get photographic dye into her bloodstream, which in turn would mean that she would have to be sedated. When the anesthesiologist arrived, he was kitted out in a ''sterile exhaust system,'' a protective suit much more elaborate than the gown and other gear Anderson and the nurses wore. This was by no means standard procedure. Such suits are meant to be used only by orthopedic surgeons during bone-replacement surgeries, which have a high potential for infection. The orthopedists, according to Anderson, were angry when they found out: ''They didn't know whether this guy had contaminated their very expensive space suit and ruined it.'' 

Fear of the unknown is potent. But for doctors and nurses, with a bone-deep understanding of mortality rates, fear of the known can be just as galvanizing. That's why monkeypox, when it first arose in the Midwest, so frightened people. Most thought it was something else. ''I remember I was sitting at my desk on Wednesday, June 4,'' said Dr. Greg Huhn, a member of the C.D.C.'s epidemic intelligence service assigned to the Illinois Department of Public Health. ''My supervisor came in and said there was a report from Wisconsin that there might be an orthopox virus there. I looked at him and said, 'Monkeypox?' He said, 'Maybe.' Then I said, 'Wait a minute, orthopox? We should be thinking smallpox.' And he said, 'Yes, we should.' '' 

That same thought swept through every hospital where patients turned up, beginning on May 22 in Marshfield, Wis., a town about 150 miles northwest of Milwaukee. Several days earlier, a 3-year-old girl from nearby Dorchester was nipped by one of her mother's prairie dogs and developed a rash and fever of about 103. Her doctors were baffled and concerned. (One of the Marshfield clinic's medical assistants developed a fever and rash. So did her boyfriend. She became convinced they had caught the girl's illness. Neither, in fact, had been infected by monkeypox.) It was two weeks before doctors would determine that the child and her parents had monkeypox. In the intervening days, doctors and nurses worried. 

''Nowadays, any time there's an outbreak of a strange disease, some people will probably think bioterrorism,'' Donald Henderson said. ''There was no evidence whatsoever of that in this case. But I imagine people thought about it, especially if they believed it might be smallpox.'' 

Dr. Paul Hunter doesn't mind admitting that he thought about it. Hunter, who lives in Milwaukee, treated one of the other monkeypox cases in late May. His patient was a meat inspector and a dealer in exotic pets, whose kitchen was stacked with cages of chattering prairie dogs and chinchillas. ''We thought he might have contracted tularemia or plague,'' Hunter said. But when the man didn't respond to antibiotics, and his rash erupted with oozing sores, Hunter and his colleagues reluctantly began to harbor other suspicions. ''The rumor about smallpox went around the hospital fast,'' he said. 

At that point, Hunter's worry shifted from the patient's prognosis to his own. ''My attitude was, I'm going to stay as far away from this guy as possible,'' he said later. Although Hunter was the attending physician and visited his patient in the isolation ward every day, he limited hands-on care as much as possible. ''I wanted to keep him comfortable,'' he said, ''but also not touch him.'' His sentiments were widely shared by the medical staff. ''Everybody did their jobs, but they wanted to have as little direct contact with him as possible. They were all like: 'Stay away!' '' 

Two days after the patient was admitted, he told Hunter that he'd like to be transferred. ''I said, 'Great, get him out of here,' '' Hunter recalled. 

''Look,'' he continued, ''I'm not a coward. I've had needle sticks. I've had to get H.I.V. and hepatitis tests and then wait around for the results. That's not fun. But it's part of the job.'' This case, he says, was different. ''I have three kids, all under the age of 11. That's a big reason I didn't want to be involved if it was smallpox. I'm not going to volunteer for anything dangerous.'' He also declined to get a smallpox vaccination. ''I said, 'You're not turning me into a first responder.' Next time, let somebody without kids handle this.'' 

Dr. Peter Singer, the director of the University of Toronto Joint Center for Bioethics, has thought a great deal about the limits of doctors' and nurses' professional and moral responsibilities. The co-author of an influential report about medical ethics issued in the wake of Toronto's SARS outbreak, he's also a husband and father, whose physician wife volunteered on a SARS ward. This, he says, was ''an extremely tough decision'' for a family with three young children. 

''Do we in medicine have a higher obligation to treat the sick than do passersby on the street?'' he asked during a telephone interview in March. ''Yes. We accept an added level of personal risk, just as policemen and firemen do. But,'' he added, ''that added risk has limits. We have an expectation that firemen will enter a burning building. We don't have an expectation that they'll jump into a burning pit and self-immolate.'' 

The difficulty is that, in practice, the boundary separating good medicine from suicide is unmarked. Every doctor and nurse may locate it differently. 

''I would never blame anybody who decided they couldn't'' treat infectious patients, said Dr. Mark Cheung, an internist in Toronto who did. Unfortunately, during one shift in a SARS ward, when he was protected by only the standard gown, latex gloves, goggles and a face mask -- considered adequate at that time, Cheung said -- he contracted SARS and became seriously ill. His family had to be quarantined. Even now, his youngest daughter fears it might happen again. ''She said to my wife a few months ago, 'I hope Dad doesn't volunteer if there's another outbreak,' '' Cheung said. But, he added, ''I will.'' 

And it's that attitude that cheers the people in public health who'd be overseeing outbreak-control measures when the next epidemic or emergency comes. ''There's a huge spectrum of responses to risk,'' said Gerberding of the C.D.C. ''Some people deny it exists, which can be dangerous if it means they're not vigilant about following precautions. Some people are so obsessed with the dangers that they simply can't respond. But most say, 'I have a job to do,' and they do it.'' 

Back in Rockford, the medical community still vibrates with the after-effects of its brush with monkeypox. ''We do expect that we'll see other outbreaks of other dangerous, infectious diseases that are a threat to the community,'' Kelly told me. This year, the C.D.C. developed a memorandum of agreement with selected hospitals across the country that were being asked to prepare themselves to accept patients in the event of an emergency quarantine. Kelly spoke with the C.D.C. and was told that hers was the first Rockford hospital to return a call from them concerning the memorandum. She did not want SwedishAmerican to also be alone on the front line. ''At that point,'' she said, ''I had to ask: Why should we carry the whole burden?'' 

Rebecca McLester has fully recovered, although she has hints of scars. During an interview at a Burger King in March, she polished off a Whopper, pinched herself and pointed to where a faint circle prickled the skin, the last shadows of a pox lesion. A few of these show up on her arms and legs when she's very cold or has just gotten out of a hot bath. ''I was the worst case in the country,'' she said with some pride. Her parents were less sanguine. ''This whole thing was awful,'' Amy Boonos said. ''Becca's scared of hospitals now. She's scared of doctors. That's a pretty hard thing for a 10-year-old kid.'' 

Michael Anderson, who has accepted a new position at a hospital in the Southeast, described the monkeypox case as ''an eye-opening experience for me.'' His most vivid memory of the six days he spent dealing with monkeypox is of a night that he and his wife, the bedside nurse, spent tending to Rebecca as she lay in a morphine-deepened sleep. Usually a hospital shuffles with restless noise, even after hours, but the isolation unit and its long lead-up corridor were deserted and silent. ''I looked at Stephanie and said, 'This is why we went into health care.' It was beautiful. But it was eerie. It's not often in a hospital that you're so alone.'' 

Last October, Anderson was invited to speak at the annual meeting of the Infectious Diseases Society of America. His topic was ''A Possible Clinical and Public Health Crisis at Your Door: What Do You Do?'' His audience, most of them infectious-disease experts, was ''mesmerized,'' a conference organizer said. 

''I said to them, 'Look, if this can happen in Rockford,' '' Anderson said, '' 'it can happen anywhere.' '' Afterward, doctors told him how much he'd inspired them. But some harbored silent qualms. In a straw poll taken at his presentation, a majority of attendees at the session said they hadn't and still wouldn't accept a smallpox vaccination. A study published that fall in the journal Health Affairs found that only 33 percent of doctors would treat smallpox without having themselves been vaccinated; and just 55 percent of the doctors surveyed agreed that physicians have an obligation to care for patients even if it might endanger their own health. The report's authors, Dr. Matthew Wynia and Dr. Caleb Alexander, both of the University of Chicago, noted, ''The threat of new disease outbreaks, from bioterrorism or natural causes, has provided an opportunity for physicians to rearticulate and reaffirm longstanding ethical principles regarding the duty to treat.'' It remains unclear whether doctors will seize that opportunity or hide from it. 

Back in the pediatrics ward at SwedishAmerican, life has returned to normal. Linda Wildey is back to her routine of supervising nurses. Her smallpox vaccination, however, has permanently changed her position in the medical world. ''I'm on the hit list now,'' she said with a small laugh. ''I know I'll get called up the next time, if there is a next time.'' And she's comfortable with that, for the most part. ''My kids are grown,'' she said. ''If they were still at home, it might be different. I might not have volunteered.'' 

About 10 days after she was vaccinated, five days after Rebecca McLester was released and long after any fear of contracting monkeypox should have passed, Wildey noticed a sore on her big toe. ''The Health Department shows up,'' she said. ''They scrape the skin. We're all standing around, staring at my big toe, saying, 'Huh.' '' The sore, samples of which were sent to the C.D.C. for testing, turned out to be an infected hair follicle. ''I felt kind of foolish after that,'' Wildey said. ''But you can't help thinking about the bad things that it could have been. I'm really glad that that little girl is better and that I could help with that. But you do wonder.'' 
 

Gretchen Reynolds is a writer living in Santa Fe.