AS THE Bush administration beats the drums for war with Iraq, public health perspectives have been notably absent from the debate over the wisdom of such a conflict. The case against this war can be made on two fronts -- one Iraqi, the other American.

Attacking Iraq may satisfy President Bush's short-term political goals and may even succeed in removing Iraq's despotic ruler, but the cost in terms of the health of 22 million Iraqis would be enormous. There would be large numbers of deaths, both military and civilian. But the real public health disaster would surface in the war's aftermath.

Widespread disease and starvation will afflict millions inside and outside Iraq as basic economic and political systems would be destroyed and refugees would flood Iraq's already unstable neighboring countries. Anti-Americanism would become more virulent, further destabilizing the Middle East and giving terrorists a more immediate grievance against the United States.

War with Iraq could also lead to a public health catastrophe in this country.

Although clearly a power-hungry tyrant, Saddam Hussein has proved over the past 23 years that he is not suicidal. If Mr. Hussein were to pre-emptively use weapons of mass destruction against the United States, he knows we would destroy him and his country.

But if we attack Iraq with the obvious intent of removing Mr. Hussein from power, he would have little to lose by attacking the United States and its allies, perhaps through terrorist groups, in a desperate attempt to maintain power. The consequences would be horrific.

Consider a potential scenario for a biological attack:

A terrorist group releases aerosolized smallpox, which U.S. intelligence believes Iraq possesses, simultaneously at BWI, Dulles and other airports in major American cities. Thousands of unwitting victims would travel throughout Maryland, the United States and the world. Symptoms would only be evident seven to 17 days later as the deep pustules of smallpox began to appear. With the onset of these symptoms, the pestilence would reach its most contagious stage and cause a worldwide epidemic before authorities could react.

The disease-ridden not only would infect family members and friends but also health care workers, who would then be among the next wave of patients. The epidemic would spread quickly, and our health care system would teeter on the brink of collapse. Even though round-the-clock emergency vaccination clinics would go into action in the hopes of stopping the epidemic, health care facilities not already quarantined or closed because of ill workers rapidly would be overloaded with the ill and dying desperately searching for help. Routine medical emergencies would go untreated.

About 30 percent of those who developed smallpox would die a very painful death -- a death toll that could be in the hundreds of thousands in the Baltimore region alone. Many more would suffer serious nonfatal consequences, including blindness and disfigurement. The toll could be even greater if terrorists chose a genetically engineered agent or one that causes an even deadlier disease.

The Bush administration argues that the above scenario can be avoided through "pre-event" mass vaccination. At first glance, this type of preventive vaccination plan would seem an appropriate response. But a massive smallpox vaccination program has serious public health consequences. Based on past experience, it could be expected that one of every million people immunized would die and many more would have serious nonfatal complications.

Additionally, millions of Americans would fall into vaccination risk groups, including the immune-compromised (including HIV/AIDS patients and cancer survivors), pregnant women, young children and those with skin conditions such as eczema. These groups could not be immunized in a pre-event setting, nor could those in close contact with them because the vaccine is a live virus that would be dangerous to these people.

Significant groups would therefore remain susceptible in the case of an attack, which diminishes the "herd immunity" that is one of the primary benefits of mass vaccination.

Smallpox was eradicated worldwide in 1977. Our concern for smallpox, therefore, is limited to the potential for a terrorist attack. Wouldn't it be far more prudent -- and safer for our country and others -- to avoid provoking an attack by halting our plans for a pre-emptive war on Iraq?

Peter Beilenson, a medical doctor, is the health commissioner of Baltimore City.