This compendium of articles provides a clear view of the factors affecting the health of Americans and the role of public health, medical care, and the community in ensuring the nation's health. The Seventh Edition continues the emphasis of earlier editions on the health of the population, the determinants of health, women's health, long term care, and the precarious set of circumstances faced by the nation's public health and health care systems as we begin the 21st century.

New issues, particularly related to bioterrorism and community health are addressed in this edition. This volume also includes coverage of tobacco, immunizations, HIV/AIDS, environmental health, dietary guidelines, physical activity, and food safety. In addition, a major new feature is an article on community problem solving, emphasizing a multidisciplinary approach to collaborative practice and research to improve community health.

The anthrax attacks in fall 2001, and the fear and confusion that followed, made it all too clear that the United States lacks a comprehensive strategy for coping with bioterrorism. For too long, thinking about biological weapons has been held hostage to misplaced analogies to nuclear or chemical weapons. An effective strategy must begin by focusing on the special challenges posed by biological threats.

Reprinted in R.D. Howard and R.L. Sawyer, eds., Terrorism and Counterterrorism: Understanding the New Security Environment (Guilford, CT: McGraw-Hill/Dushkin, 2002), pp. 174-184.

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.

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.