The Nation's capacity to respond to bioterrorism depends in part on the ability of clinicians and public health officials to detect, manage, and communicate during a bioterrorism event. Information technologies and decision support systems (IT/DSSs) have the potential to aid clinicians (e.g., physicians, nurses, nurse practitioners, and respiratory therapists) and public health officials to respond effectively to a bioterrorist attack.

The Evidence Report from which this summary was taken details the methodology, results, and conclusions of a systematic and extensive search for published materials on the use of IT/DSSs to serve the information needs of clinicians and public health officials in the event of a bioterrorist attack. The information is intended to assist clinicians, public health officials, and policymakers to improve preparedness for a bioterrorism event.

The United States is in the midst of its third major debate on nationwide ballistic missile defense-the first culminating in the 1972 ABM Treaty and the second sparked by President Reagan's "Star Wars" speech in 1983. This time the Cold War is over, the objectives for the defense are limited, and technology has advanced to the point where some options may be technically feasible.

However, intercontinental ballistic missiles (ICBMs) are not the primary threat to the United States, as events since September 11 demonstrate. Other homeland defense programs, especially civil defenses against bioterrorism, are more important. Yet emerging missile states may acquire ICBMs some day. To the extent that this is a concern, diplomatic efforts can limit the spread of ballistic missiles, and deterrence can dissuade their use. National missile defense (NMD), then, is insurance against the relatively unlikely event that ICBMs will be launched against the United States.

If the United States decides to deploy a limited NMD, the questions become what type and how much? A midcourse NMD system (one that attempts to intercept missile warheads as they fall through outer space) of the sort proposed for deployment in Alaska is the most technically mature option and would probably work well enough against emerging ICBM threats to justify limited deployment, assuming that the threat materializes. However, such a defense should contain only about 20 interceptors to minimize adverse political reactions from Russia and China. Over the long run, midcourse defenses may be vulnerable to sophisticated countermeasures. Therefore, the United States should place greater emphasis on land, naval, and air-based boostphase intercept options (defenses that attempt to intercept the ballistic missile while its rocket motors are still burning) because they are more robust to countermeasures and they pose relatively little threat to Russia and China. Space-based boost-phase NMD systems have the advantage of global coverage; however, they are technically more challenging, probably more expensive, and more destabilizing.

The official U.S. government policy is to maintain "calculated ambiguity" about whether the United States would retaliate with nuclear weapons in response to an adversary's use of chemical weapons (CW) or biological weapons (BW) against U.S. allies, U.S. armed forces overseas, or the U.S. homeland. Since the 1991 Gulf War, numerous civilian and military leaders have stated that the United States might use nuclear weapons in response to CW and BW threats or attacks, and some have even stated that the United States will use nuclear weapons in such circumstances. The central argument in my spring 2000 International Security article was that this policy has created a dangerous "commitment trap" problem.

The benefit of making such nuclear threats, whether stated ambiguously or clearly, is that they can increase an adversary's estimate of the probability that the U.S. president would order nuclear retaliation, which should therefore decrease the likelihood of chemical or biological weapons attacks. But there is a serious cost attached to this obvious benefit: If deterrence fails despite nuclear threats, the statements will also increase the likelihood that the United States will actually use nuclear weapons, because the president's personal and the U.S. government's institutional reputations for following through on threats would be perceived to be at stake.

I argued that current U.S. nuclear doctrine has therefore created a subtle dilemma that has not been recognized, much less debated, in both policy and academic circles: Is the improvement in the U.S. ability to deter CW and BW threats worth the increased likelihood of a U.S. nuclear response if deterrence fails?

A biological terrorist attack probably would first be detected by doctors or other health-care workers. The speed of a response would then depend on their rapid recognition and communication that certain illnesses appeared out of the ordinary. For this reason, preparing for biological terrorism has more in common with confronting the threat of emerging infectious diseases than with preparing for chemical or nuclear attacks. Defense against bioterrorism, like protection against emerging diseases, must therefore rely on improved national and international public-health surveillance. Too often, thinking about bioterrorism has mimicked thinking about chemical terrorism, a confusion that leads to an emphasis on the wrong approaches in preparing to meet the threat.

How should the United States deal with so-called rogue states that threaten to use chemical or biological weapons against the U.S. homeland or its troops abroad? Scott Sagan of Stanford University examines Washington's "calculated ambiguity doctrine," which holds that the United States does not rule out the use of nuclear weapons in response to a chemical or biological weapons attack. Sagan argues that the risks associated with this doctrine outweigh the benefits. He warns that although the ambiguity doctrine might decrease the likelihood of a chemical or biological attack, it also raises the probability that Washington would feel compelled to use nuclear weapons to respond to such an attack. Sagan concludes that the United States should renounce the nuclear option and instead recommit itself to meeting a chemical or biological attack with overwhelming conventional force.