Bioterrorism is a relatively new public health concern. The first citation in MedLine appeared only eight years ago (Stephenson 1996), but as of mid-June 2004 MedLine contained almost 2,400 citations on the subject. The dominant concerns are understanding the public health consequences of bioterrorism and planning responses to any future episodes. Those two topics are at the heart of the first article in this issue of the Milbank Quarterly. In “Emotional and Behavioral Consequences of Bioterrorism: Planning a Public Health Response,” Bradley Stein, Terri Tanielian, David Eisenman, Donna Keyser, Audrey Burnam, and Harold Pincus combine a literature review and interview data from expert informants in a discussion of what is known about the effects of bioterrorism, as well as implications for preparing for future attacks.

Stein and colleagues analyze how bioterrorism compares with somewhat similar events with which we have more experience, including epidemics, large-scale accidents, and natural disasters, and they summarize the available evidence regarding people’s psychological and emotional response to large catastrophic events. The authors consider four affected populations: direct victims, the general public, first responders, and people whose personal characteristics may heighten their psychological or emotional vulnerability. Based on the literature and their interviews, Stein and his colleagues suggest needed actions and future priorities for policy and research. They emphasize the uncertainty surrounding certain threats (e.g., people may not know whether they have been exposed to an agent), the fact that both the exposure and response may be prolonged (e.g., if contagion is involved), and the importance of how public officials communicate about risk. More broadly, they provide information to assist policymakers and members of their staffs to take account of what is known about the potential emotional and behavioral responses to a bioterrorist attack.

The second article in this issue examines another topic for which communication is increasingly important: the care of the 60 million Americans who have multiple chronic conditions. In “Using Electronic Health Records to Help Coordinate Care,” Lynda Burton, Gerard Anderson, and Irvin Kues assess the current and potential use of electronic health records in the United States. They describe various efforts now under way to develop information technology to improve communication among the health professionals who may be involved in caring for patients with more than one chronic disease, and they discuss barriers to the development of this technology and how they are being addressed. They conclude with suggestions regarding the creation of a common health record, the establishment of regional organizational structures to facilitate the exchange of health information, and the need for purchasers to reward the use of electronic health records.

The Burton, Anderson, and Kues article addresses a recurrent theme in the Quarterly: improving the performance of the health care system. The third article in this issue is concerned with improved performance at the individual level. In “Cognition-Enhancing Drugs,” Maxwell Mehlman carefully examines the legal and ethical issues and public policy questions arising from the greater availability of drugs affecting individuals’ cognitive performance. Drugs for treating cognitive problems related to clinical conditions (e.g., Alzheimer’s disease) may also improve cognition in healthy people. After describing current and emerging pharmaceutical developments, Mehlman considers the possible consequences (benefits and detriments) of, as well as the ethical objections to, their general use. After rejecting those objections, he turns to policy recommendations aimed at (1) safety and efficacy, (2) fairness and equity (which would involve governmental subsidies), and (3) voluntariness, or the freedom to decide whether to use cognition-enhancing drugs.

The economic viability of the Social Security system has broad implications for the American people and has a complex relationship to the goals of health policy. In the fourth article in this issue, Jan Ostermann and Frank Sloan examine whether and how the consumption of alcohol affects the Social Security system. In “The Effect of Heavy Drinking on Social Security Old-Age and Survivors Insurance Contributions and Benefits,” they use data from several sources to estimate how much the consumption of alcohol affects the amount that individuals pay into the Social Security system and how much they receive in benefits.

Ostermann and Sloan find that reduced alcohol consumption among heavy drinkers increases the amount that they pay into the Social Security system but it increases Social Security outlays even more, because of the larger benefits paid to, and longer survival of, recipients. They argue that projections for the Social Security Trust Fund need to take account of possible longevity gains that could result from improved health habits of the population.

The final article explores another social insurance issue: workers’ compensation. Thomas Wickizer and colleagues describe an innovative approach to improving the quality of care for injured workers and reducing expenditures in the workers’ compensation system in the state of Washington. In “A Communitywide Intervention to Improve Outcomes and Reduce Disability among Injured Workers in Washington State,” Wickizer and colleagues describe collaboration between the Department of Labor and Industries and the University of Washington. This initiative builds on an earlier project (Wickizer et al. 2001) that used a managed care approach to care for injured workers. This new collaboration uses various quality improvement activities inspired by the Institute of Medicine’s Crossing the Quality Chasm (2001). Wickizer and his colleagues report initial success in engaging physicians and health care institutions in this effort to improve the quality of care of injured workers.

Bradford H. Gray
Editor, The Milbank Quarterly


Institute of Medicine. 2001. Crossing the Quality Chasm. Washington, D.C.: National Academy Press.

Stephenson, J. 1996. Confronting a Biological Armageddon: Experts Tackle Prospect of Bioterrorism. Journal of the American Medical Association 276(5):349–51.

Wickizer, T.M., G. Franklin, R. Plaeger-Brockway, and R.D. Mootz. 2001. Improving the Quality of Workers’ Compensation Health Care Delivery: The Washington State Occupational Health Services Project. Milbank Quarterly 79(1):5–33.

Author(s): Bradford H. Gray

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Volume 82, Issue 3 (pages 409–411)
DOI: 10.1111/j.0887-378X.2004.00316.x
Published in 2004