Interest in nuclear disarmament has grown rapidly in recent years. Starting with the 2007 Wall Street Journal article by four former U.S. statesmen-George Shultz, Henry Kissinger, William Perry, and Sam Nunn-and followed by endorsements from similar sets of former leaders from the United Kingdom, Germany, Poland, Australia, and Italy, the support for global nuclear disarmament has spread. The Japanese and Australian governments announced the creation of the International Commission on Nuclear Non-Proliferation and Disarmament in June 2008. Both Senators John McCain and Barack Obama explicitly supported the vision of a world free of nuclear weapons during the 2008 election campaign. In April 2009, at the London Summit, President Barack Obama and President Dmitri Medvedev called for pragmatic U.S. and Russian steps toward nuclear disarmament, and President Obama then dramatically reaffirmed "clearly and with conviction America's commitment to seek the peace and security of a world without nuclear weapons" in his speech in Prague.

There is a simple explanation for these statements supporting nuclear disarmament: all states that have joined the Nuclear Non-Proliferation Treaty (NPT) are committed "to pursue negotiations in good faith on effective measures relating to cessation of the nuclear arms race at an early date and to nuclear disarmament." In the United States, moreover, under Clause 2 of Article 6 of the Constitution, a treaty commitment is "the supreme Law of the Land." To af1/2rm the U.S. commitment to seek a world without nuclear weapons is therefore simply promising that the U.S. government will follow U.S. law.

A closer reading of these various declarations, however, reveals both the complexity of motives and the multiplicity of fears behind the current surge in support of nuclear disarmament. Some declarations emphasize concerns that the current behavior of nuclear-weapons states (NWS) signals to non-nuclear-weapons states (NNWS) that they, too, will need nuclear weapons in the future to meet their national security requirements. Other disarmament advocates stress the growth of global terrorism and the need to reduce the number of weapons and the amount of fissile material that could be stolen or sold to terrorist groups. Some argue that the risk of nuclear weapons accidents or launching nuclear missiles on false warning cannot be entirely eliminated, despite sustained efforts to do so, and thus believe that nuclear deterrence will inevitably fail over time, especially if large arsenals are maintained and new nuclear states, with weak command-and- control systems, emerge.

Perhaps the most widespread motivation for disarmament is the belief that future progress by the NWS to disarm will strongly influence the future willingness of the NNWS to stay within the NPT. If this is true, then the choice we face for the future is not between the current nuclear order of eight or nine NWS and a nuclear-weapons- free world. Rather, the choice we face is between moving toward a nuclear- weapons-free world or, to borrow Henry Rowen's phrase, "moving toward life in a nuclear armed crowd."

There are, of course, many critics of the nuclear disarmament vision. Some critics focus on the problems of how to prevent nuclear weapons "breakout" scenarios in a future world in which many more countries are "latent" NWS because of the spread of uranium enrichment and plutonium reprocessing capabilities to meet the global demand for fuel for nuclear power reactors. Others have expressed fears that deep nuclear arms reductions will inadvertently lead to nuclear proliferation by encouraging U.S. allies currently living under "the U.S. nuclear umbrella" of extended deterrence to pursue their own nuclear weapons for national security reasons. Other critics worry about the "instability of small numbers" problem, fearing that conventional wars would break out in a nuclear disarmed world, and that this risks a rapid nuclear rearmament race by former NWS that would lead to nuclear first use and victory by the more prepared government.

Some critics of disarmament falsely complain about nonexistent proposals for U.S. unilateral disarmament. Frank Gaffney, for example, asserts that there has been "a 17 year-long unilateral U.S. nuclear freeze" and claims that President Obama "stands to transform the ‘world's only superpower' into a nuclear impotent." More serious critics focus on those problems-the growth and potential breakout of latent NWS, the future of extended deterrence, the enforcement of disarmament, and the potential instability of small numbers-that concern mutual nuclear disarmament. These legitimate concerns must be addressed in a credible manner if significant progress is to be made toward the goal of a nuclear-weapons-free world.

To address these problems adequately, the current nuclear disarmament effort must be transformed from a debate among leaders in the NWS to a coordinated global effort of shared responsibilities between NWS and NNWS. This essay outlines a new conceptual framework that is needed to encourage NWS and NNWS to share responsibilities for designing a future nuclear-fuel-cycle regime, rethinking extended deterrence, and addressing nuclear breakout dangers while simultaneously contributing to the eventual elimination of nuclear weapons.

New technologies, including prescription drugs and medical devices, are a major driver of increases in U.S. health care expenditures, which have grown by an estimated 71% since 2000.1 The U.S. market for drugs and devices is regulated by the Food and Drug Administration (FDA), which scrutinizes clinical trial data for evidence of safety and efficacy. Although the FDA has been criticized for missteps and inefficiencies in its approval process, these are not the causes of increasing health care expenditures. More relevant is FDA oversight of the labeling and promotion of medical products.

Project development is particularly challenging in “frontier” environments where alternative technologies, conflicting laws and agencies, and uncertain benefits or risks constrain the knowledge or decisions of participants.  Carbon capture and storage (“CCS”) projects by means of geologic sequestration are pursued in such an environment.  In these circumstances, entrepreneurs can seek to employ two distinct types of tools:  the game-changer, being an improvement to the status quo for all those similarly situated, generally achieved through collective or governmental action; and the finesse, being an individualized pursuit of an extraordinary project that is minimally affected by a given legal, business or technological obstacle.  These techniques are illustrated in the case of CCS as to ownership of property rights, carbon dioxide (“CO2”) transportation economics, liability for stored CO2 following the closure of injection wells, inter-agency and federal-state conflicts, competing technologies, and uncertain economic or legal incentives.  The finesse and the game-changer should also be useful concepts for creative solutions in other applications.

This article seeks to explain why two states faced with a similar terrorist threat, perceiving it in a similar way, and drawing the same broad implications for their counterterrorist investigations, have nevertheless put in place significantly different types of organizational
reforms in response to that threat. The study shows that although France and Britain have embraced a common preventive logic in the face of Islamist terrorism, the changes that they have made to the coordination of intelligence, law enforcement, and prosecution in that context have differed because of contrasting organizational routines and interinstitutional conventions in the two states. An analysis of the British and French cases shows that law enforcement can be preventive but that western states are likely to pursue different ways of bringing security agencies and the law together to prevent and prosecute terrorism. The organizational and institutional factors that give rise to such divergent practices have important consequences for the ability of a state to develop a coordinated operational response to terrorism and convict terrorist suspects of crimes in a court of law.

Background Optimal treatment for patients with both type 2 diabetes mellitus and stable ischemic heart disease has not been established.

Methods We randomly assigned 2368 patients with both type 2 diabetes and heart disease to undergo either prompt revascularization with intensive medical therapy or intensive medical therapy alone and to undergo either insulin-sensitization or insulin-provision therapy. Primary end points were the rate of death and a composite of death, myocardial infarction, or stroke (major cardiovascular events). Randomization was stratified according to the choice of percutaneous coronary intervention (PCI) or coronary-artery bypass grafting (CABG) as the more appropriate intervention.

Results At 5 years, rates of survival did not differ significantly between the revascularization group (88.3%) and the medical-therapy group (87.8%, P=0.97) or between the insulin-sensitization group (88.2%) and the insulin-provision group (87.9%, P=0.89). The rates of freedom from major cardiovascular events also did not differ significantly among the groups: 77.2% in the revascularization group and 75.9% in the medical-treatment group (P=0.70) and 77.7% in the insulin-sensitization group and 75.4% in the insulin-provision group (P=0.13). In the PCI stratum, there was no significant difference in primary end points between the revascularization group and the medical-therapy group. In the CABG stratum, the rate of major cardiovascular events was significantly lower in the revascularization group (22.4%) than in the medical-therapy group (30.5%, P=0.01; P=0.002 for interaction between stratum and study group). Adverse events and serious adverse events were generally similar among the groups, although severe hypoglycemia was more frequent in the insulin-provision group (9.2%) than in the insulin-sensitization group (5.9%, P=0.003).

Conclusions Overall, there was no significant difference in the rates of death and major cardiovascular events between patients undergoing prompt revascularization and those undergoing medical therapy or between strategies of insulin sensitization and insulin provision. (ClinicalTrials.gov number, NCT00006305.)

The members of the writing group (Robert L. Frye, M.D., Mayo Clinic, Rochester, MN; Phyllis August, M.D., M.P.H., New York Hospital Queens, Queens, NY; Maria Mori Brooks, Ph.D., Regina M. Hardison, M.S., Sheryl F. Kelsey, Ph.D., Joan M. MacGregor, M.S., and Trevor J. Orchard, M.B., B.Ch., University of Pittsburgh, Pittsburgh; Bernard R. Chaitman, M.D., Saint Louis University, St. Louis; Saul M. Genuth, M.D., Case Western Reserve University, Cleveland; Suzanne H. Goldberg, R.N., M.S.N., National Heart, Lung, and Blood Institute, Bethesda, MD; Mark A. Hlatky, M.D., Stanford University, Palo Alto, CA; Teresa L.Z. Jones, M.D., National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD; Mark E. Molitch, M.D., Feinberg School of Medicine, Northwestern University, Chicago; Richard W. Nesto, M.D., Lahey Clinic Medical Center, Burlington, MA; Edward Y. Sako, M.D., Ph.D., University of Texas Health Science Center, San Antonio; and Burton E. Sobel, M.D., University of Vermont, Burlington) assume responsibility for the overall content and integrity of the article.

As pressure builds on the White House and Congress to deliver on their promise of health care reform, the idea of a government health insurance company to compete with for-profit and not-for-profit private companies is gaining political momentum. Advocates claim that this new company would be more efficient, honest, and successful in forcing lower reimbursement rates on physicians and hospitals. However, a close look at how the present health care system functions, what its major problems are, and what reforms are needed to solve them suggests that this new idea is not the answer. The three major problems of the current U.S. system are that 45 million to 50 million people have no health insurance, the cost of care is high and rapidly increasing, and there are gross lapses in the quality of care. There is no reason to think that a government insurance company would make a significant dent in any one of these problems, let alone all three. To do that would require real reform in the financing, organization, and delivery of care.

Background

Although the Accreditation Council for Graduate Medical Education (ACGME) limits the work hours of residents, concerns about fatigue persist. A new Institute of Medicine (IOM) report recommends, among other changes, improved adherence to the 2003 ACGME limits, naps during extended shifts, a 16-hour limit for shifts without naps, and reduced workloads.

Methods

We used published data to estimate labor costs associated with transferring excess work from residents to substitute providers, and we examined the effects of our assumptions in sensitivity analyses. Next, using a probability model to represent labor costs as well as mortality and costs associated with preventable adverse events, we determined the net costs to major teaching hospitals and cost-effectiveness across a range of hypothetical changes in the rate of preventable adverse events.

Results

Annual labor costs from implementing the IOM recommendations were estimated to be $1.6 billion (in 2006 U.S. dollars) across all ACGME-accredited programs ($1.1 billion to $2.5 billion in sensitivity analyses). From a 10% decrease to a 10% increase in preventable adverse events, net costs per admission ranged from $99 to $183 for major teaching hospitals and from $17 to $266 for society. With 2.5% to 11.3% decreases in preventable adverse events, costs to society per averted death ranged from $3.4 million to $0.

Conclusions

Implementing the four IOM recommendations would be costly, and their effectiveness is unknown. If highly effective, they could prevent patient harm at reduced or no cost from the societal perspective. However, net costs to teaching hospitals would remain high.