OBJECTIVE: In 1976, the Committee on Perinatal Health recommended that hospitals with no neonatal intensive care unit (NICU) or intermediate NICUs transfer high-risk mothers and infants that weigh 2000 g to a regional NICU. This standard was based on expert opinion and has not been validated carefully. This study evaluated the effect of NICU level and patient volume at the hospital of birth on neonatal mortality of infants with a birth weight (BW) of 2000 g.

METHODS: Birth certificates of 16 732 singleton infants who had a BW of 2000 g and were born in nonfederal hospitals in California in 1992 and 1993 were linked to death certificates and to discharge abstracts. The hospitals were classified by the level of NICU: no NICU, no intensive care; intermediate NICU, intermediate intensive care; community NICU, expanded intermediate intensive care; and regional NICU, tertiary intensive care. A logistic regression model that controlled for demographic risks, diagnoses, transfer, average NICU census, and NICU level was estimated using death within the first 28 days or first year of life if continuously hospitalized as the main outcome measure.

RESULTS: Compared with birth in a hospital with a regional NICU, risk-adjusted mortality of infants with BW of 2000 g was higher when birth occurred in hospitals with no NICU (odds ratio [OR]: 2.38; 95% confidence interval [CI]: 1.81-3.13), an intermediate NICU (OR: 1.92; 95% CI: 1.44-2.54), or a small (average census 15) community NICU (OR: 1.42; 95% CI: 1.14-1.76). Risk-adjusted mortality for infants who were born in hospitals with a large (average census > or =15) community NICU was not statistically different compared with those with a regional NICU (OR: 1.11; 95% CI: 0.87-1.43). Except for large community NICUs, all of these ORs are larger when the data are restricted to infants with BW of 1500 g or BW of 1250 g and smaller for BW between 1250 g and 1999 g and 1500 g and 1999 g. For large community NICUs, the results are similar for the smaller BW intervals and significant only for the larger BW interval.

CONCLUSIONS: These results support the recommendation that hospitals with no NICU or intermediate NICUs transfer high-risk mothers with estimated fetal weight of 2000 g to a regional NICU. For infants with BW of 2000 g, birth at a hospital with a regional NICU is associated with a lower risk-adjusted mortality than birth at a hospital with no NICU, intermediate NICU of any size, or small community NICU. Subsequent neonatal transfer to a regional NICU only marginally decreases the disadvantage of birth at these hospitals. The evidence for the few hospitals with large community NICUs is mixed. Although the data point to higher mortality in large community NICUs, they are not conclusive and additional study is needed on the mortality effects of large community NICUs. Greater efforts should be made to deliver infants with expected BW of 2000 g at hospitals with regional NICUs.

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.

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.

Lengthy travel distances may explain why relatively few veterans in the United States use VA hospitals for inpatient medical/surgical care. We used two approaches to distinguish the effect of distance on VA use from other factors such as access to alternatives and veterans' characteristics. The first approach describes how disparities in travel distance to the VA are related to other characteristics of geographic areas. The second approach involved a multivariate analysis of VA use in postal zip code areas (ZCAs). We used several sources of data to estimate the number of veterans who had priority access to the VA so that use rates could be estimated. Access to hospitals was characterized by estimated travel distance to inpatient providers that typically serve each ZCA. The results demonstrate that travel distance to the VA is variable, with veterans in rural areas traveling much farther for VA care than veterans in areas of high population density. However, Medicare recipients also travel farther in areas of low population density. In some areas veterans must travel lengthy distances for VA care because VA hospitals which were built over the past few decades are not located close to areas in which veterans reside in the 1990s. The disparities in travel distance suggest inequitable access to the VA. Use of the VA decreases with increases in travel distance only up to about 15 miles, after which use is relatively insensitive to further increases in distance. The multivariate analyses indicate that those over 65 are less sensitive to distance than younger veterans, even though those over 65 are Medicare eligible and therefore have inexpensive access to alternatives. The results suggest that proximity to a VA hospital is only one of many factors determining VA use. Further research is indicated to develop an appropriate response to the needs of the small but apparently dedicated group of VA users who are traveling very long distances to obtain VA care.

In recent years, the hospital industry has been undergoing massive change and reorganization with technological innovations and the spread of managed care. As a result, the total number of hospitals countrywide has been declining, and a growing number of not-for-profit hospitals have converted to for-profit status. These changes raise two fundamental questions: What determines a hospital's choice of for-profit or not-for-profit organizational form? And how does that form affect patients and society?

This timely volume provides a factual basis for discussing for-profit versus not-for-profit ownership of hospitals and gives a first look at the evidence about new and important issues in the hospital industry. The Changing Hospital Industry: Comparing Not-for-Profit and For-Profit Institutions will have significant implications for public-policy reforms in this vital industry and will be of great interest to scholars in the fields of health economics, public finance, hospital organization, and management; and to health services researchers.

In recent years, the hospital industry has been undergoing massive change and reorganization with technological innovations and the spread of managed care. As a result, the total number of hospitals countrywide has been declining, and a growing number of not-for-profit hospitals have converted to for-profit status. These changes raise two fundamental questions: What determines a hospital's choice of for-profit or not-for-profit organizational form? And how does that form affect patients and society?

This timely volume provides a factual basis for discussing for-profit versus not-for-profit ownership of hospitals and gives a first look at the evidence about new and important issues in the hospital industry. iThe Changing Hospital Industry: Comparing Not-for-Profit and For-Profit Institutions will have significant implications for public-policy reforms in this vital industry and will be of great interest to scholars in the fields of health economics, public finance, hospital organization, and management; and to health services researchers.

Health care report cards - public disclosure of patient health outcomes at the level of the individual physician and/or hospital - may address important informational asymmetries in markets for health care, but they may also give doctors and hospitals incentives to decline to treat more difficult, severely ill patients. Whether report cards are good for patients and for society depends on whether their financial and health benefits outweigh their costs in terms of the quantity, quality, and appropriateness of medical treatment that they induce. Using national data on Medicare patients at risk for cardiac surgery, we find that cardiac surgery report cards in New York and Pennsylvania led both to selection behavior by providers and to improved matching of patients with hospitals. On net, this led to higher levels of resource use and to worse health outcomes, particularly for sicker patients. We conclude that, at least in the short run, these report cards decreased patient and social welfare.

In this classic book, Professor Victor Fuchs draws on his deep understanding of the strengths and limitations of economics and his intimate knowledge of health care institutions to help readers understand the problems every nation faces in trying to allocate health resources efficiently and equitably. Six complementary papers dealing with national health insurance, poverty and health, and other policy issues, including his 1996 presidential address to the American Economic Association, accompany the original 1974 text.

Health professionals, policy makers, social scientists, students and concerned citizens will all benefit from this highly readable, authoritative, and nuanced discussion of the difficult choices that lie ahead.