Prevention is an important role for all health care providers. Providers can help individuals stay healthy by preventing disease, and they can prevent complications of existing disease by helping patients live with their illnesses. To fulfill this role, however, providers need data on the impact of their services and the opportunity to compare these data over time or across communities. Local, State, and Federal policymakers also need these tools and data to identify potential access or quality-of-care problems related to prevention, to plan specific interventions, and to evaluate how well these interventions meet the goals of preventing illness and disability.

The Agency for Healthcare Research and Quality (AHRQ) Prevention Quality Indicators (PQIs) represent one such tool. Local, State, or national data collected using the PQIs can flag potential problems resulting from a breakdown of health care services by tracking hospitalizations for conditions that should be treatable on an outpatient basis, or that could be less severe if treated early and appropriately. The PQIs represent the current state of the art in measuring the outcomes of preventive and outpatient care through analysis of inpatient discharge data.

The horrifying events of 11 September 2001 serve notice that civilization will confront severe challenges in the twenty-first century. As national security budgets expand in response, we should recognize that only a broad conception of security will be adequate to meet some of the threats that we may face. Biological security provides a powerful example. It must address both the challenge of biological weapons and that of infectious disease. The right approach should benefit public health even if major acts of biological terrorism never occur. Our thinking about biological security must transcend old misplaced analogies to nuclear and chemical security.

Nuclear security has been based on nonproliferation, deterrence, and defense, with intelligence woven throughout. Nonproliferation seeks to prevent the diversion of materials from civilian programs to military or terrorist weapons. Should nonproliferation fail, the United States relies on deterrence through the threat of retaliation. Defense, active or civil, has so far been less central.

Effective biological security requires a different mix. For all its challenges, nuclear nonproliferation is comparatively robust, in part because the production of weapons-usable uranium or plutonium provides a conspicuous bottleneck through which any nuclear program must pass, unless those materials are stolen. This is why preventing nuclear theft is such a high priority in the post-Cold War world. Biological agents

are easier to acquire. Most can be found in naturally occurring outbreaks. Weaponizing these agents has proved challenging for terrorist groups, but the Aum Shinrikyo's unsuccessful efforts to spray the anthrax organism throughout Tokyo in 1993 warned that attempted mass urban attacks were no longer in the realm of the fantastic.

The transfer of dangerous biological agents should be controlled where possible, and the spread of the technologies and personnel to weaponize them should be impeded. But any biological nonproliferation regime will necessarily be less robust than its nuclear counterpart, because the relevant materials, technologies, and knowledge are far more widespread.

Biological terrorism also challenges requirements for successful deterrence. Because some diseases incubate for a week or more, identifying the perpetrators of an attack may prove difficult. A terrorist group might even hope that its attack would go unrecognized; when followers of the Bhagwan Shree Rajneesh infected 750 Oregonians with salmonella in 1984, it took over a year before the infection was determined to have been intentional. Finally, as with any form of terrorism, some groups may simply be unconcerned about retaliation.

In the face of these difficulties, good intelligence is all the more important. Warning and prevention are preferable to coping with the consequences of an attack, but we must also be ready should an attack occur. This requires that greater emphasis be placed on improving public health, a kind of homeland defense that is applicable to both unintentional and intentional disease outbreaks.

Because of disease incubation times, the first responders to a biological attack may well be health-care workers at hospitals and clinics rather than specialized units. The speed and effectiveness of a response will depend on disease surveillance: the recognition by health-care workers that certain illnesses appear unusual and the rapid notification of the proper authorities. Because incubation times often exceed international travel times, both domestic and international components are required. But the domestic component of disease surveillance in most nations, including the United States, is too weak, and international networks are inadequate. Donor nations need to increase support for these efforts. And there are many other needs, such as developing and stockpiling sufficient vaccines, antibiotics, or antivirals and otherwise preparing to meet the enormous challenges that would be posed by a major outbreak. It is time to quicken the pace of these efforts, to which departments of health are as central as departments of defense.

Disease surveillance and response are not nonproliferation measures, so cannot substitute for an effective verification regime under the Biological Weapons Convention. But biological security requires the developed world, especially the United States, to see that its ongoing self-interest is closely allied with sustainable public-health improvements in the developing world. And the explosion of biotechnology, with the weapons implications that follow from it, requires the scientific community to discuss its responsibilities in earnest.

The specter of multidrug-resistant tuberculosis (MDR-TB) threatens the gains achieved by tuberculosis control through international recommendations currently accepted by 127 countries. The high cost of second-line drugs is a clear example of a market failure serving as a barrier to treatment of MDR-TB cases. Gupta et al. describe an approach based on policy development, consolidating and increasing demand, and increasing supply to decrease the cost of second-line drugs. As a result, prices decreased from 48-97% for a treatment regimen and competition was increased in monopoly markets. An independent scientific committee fosters access to the drugs under tightly monitored pilot projects to prevent the creation of resistance to second-line drugs. This strategy may be applicable to other infectious-disease treatment efforts.

STANFORD, Calif.- For the past seven years, the United States has been negotiating a verification protocol to the Biological Weapons Convention of 1972, hoping to put teeth into the convention's ban on biological weapons production. The Bush administration recently rejected the latest draft of the protocol, viewing it as irredeemably flawed. This is a good time to ask what a new American strategy should be for security against biological threats. It is difficult to predict the likelihood or scale of biological attack. The right policy will provide benefits whether or not an attack occurs.

The first step is conceptual: we must stop thinking about biological security in the way we think about nuclear security. Few aspects of the United States strategy for nuclear security carry over cleanly to the biological case. Security against nuclear attack has relied upon nonproliferation and deterrence, with comparatively little role, so far, for defense. Security against biological-weapons threats should lean primarily on defense.

Nonproliferation, for example, is far more difficult in the biological case. Biological agents are microscopic organisms that can be grown with equipment readily available all over the world -- although the resulting weapons have proved difficult for terrorists to master. Many of the organisms can be acquired during naturally occurring outbreaks. Controls remain valuable, but they will never play the central role that they do in nuclear security. And as biotechnology explodes in the coming decades, nonproliferation will face ever greater challenges.

Deterrence may likewise be of limited use in preventing attacks with biological weapons. While the use of battlefield biological weapons may be deterred by threats, biological terrorism could remain largely immune. The incubation times of most diseases -- for example, seven to 17 days for smallpox -- may lead terrorists to hope they can cover their tracks through covert releases of biological agents. Deterrence relies on the threat of punishment. An attacker who cannot be identified cannot be threatened.

When the Aum Shinrikyo cultists sprayed an anthrax organism in Tokyo -- they did so unsuccessfully several times before their deadly 1995 nerve-gas attack -- they made no announcements and the attacks went unnoticed. When followers of the Bhagwan Shree Rajneesh infected 750 Oregonians in 1984 with salmonella, it took over a year for the attack to be distinguished from a natural outbreak.

Rather than nonproliferation and deterrence, biological security must emphasize civil defense. Civil defense in the biological realm means improving the public health system. Most important, it requires improving disease surveillance. Unusual disease outbreaks must be recognized quickly, so that a rapid response is possible. Health care workers in clinics, hospitals and private practice must know how to identify such outbreaks and be ready and able to pass their information rapidly to city, state and national authorities.

This kind of preparedness would also help to prevent unintentional outbreaks of disease. Because infected passengers can travel the world in less time than it takes for a disease to incubate, it is crucial, for the national interest as well as for humanitarian reasons, to improve disease surveillance overseas. The United States welcomes 50 million visitors every year and imports $40 billion worth of food. Disease cannot be stopped at the border. The United States must act internationally as well as nationally.

Because biological security would offer protection against both natural and nefarious transmission of disease, a sound policy would directly benefit society even if no attack ever happened. Effective biological security requires that we fit the cure to the disease.

Patient safety has received increased attention in recent years, but mostly with a focus on the epidemiology of errors and adverse events, rather than on practices that reduce such events. This project aimed to collect and critically review the existing evidence on practices relevant to improving patient safety.

Policy changes in the mid-1990s sent veterans to outpatient facilities for treatment, mirroring trends in the overall U.S. health care system.

Substance use disorders are a major problem among the nation's veterans. The U.S. Department of Veterans Affairs(VA), which provides health care to more than three million veterans, is the nation's largest provider of substance abuse treatment. The VA trains large numbers of physicians and other mental health professionals; it plays an important role in defining standards of mental health care in the United States.

In the past decade several initiatives have transformed the VA. These policies were inspired by changing views about the role and size of government and by growing use of managed care. This paper considers the effect of these changes on specialized VA programs for substance abuse treatment.