Since Jenner's time, there have always been enthusiasts and skeptics about the role of vaccines in the prevention of disease. This introduction explains why, at this time, it is crucial to assess the historical role vaccines have played in limiting damage caused by infectious diseases, the role they can play in the future, and the technologies that are best suited to achieving optimal gains for public health and development worldwide.

In Japan, screening programs for various cancers have been eagerly conducted as part of public health policy. However, these programs have not always produced the results that were originally expected. To improve the ill-planned and unscientific state of the current programs in Japan, two proposals are made.

The authors report on innovative approaches to the organization of health services and the delivery of patient care in 19 U.S. hospitals and hospital networks. Strengthening patient care is the focus of this initiative. Hospital-wide interdisciplinary planning and the subsequent trial of new human service technologies are explored.

Clinical genetics services have become an integrated part of health care in nearly all European countries. The emphasis has been on postnatal cytogenetic, biochemical, and DNA diagnosis of congenital disorders, carrier detection, genetic counseling, and prenatal diagnosis. Use has been satisfactory, and very few ethical problems have arisen, apart from moral objections against abortion by minority groups. The progress of human gene mapping is associated with new perspectives in clinical genetics and will enable the identification of people at risk of major adult diseases. This prospect has caused some concern about psychosocial and ethical issues that are being dealt with in different ways in various postindustrial societies. In future decades, however, 95% of the world's population increase will occur in developing countries. In most of these countries, a low per capita income, female illiteracy, low rates of contraceptive use, teenage pregnancy, and religious and traditional cultural factors are major complications of implementing genetic services at a global level. There are, however, some exceptions, which are discussed.

Efforts to provide the benefits of immunization to the world's children have reached an important crossroad. While remarkable progress has been achieved in successfully administering six important childhood vaccines (diphtheria, tetanus, polio, pertussis, measles, and tuberculosis), the benefits of new vaccines, such as hepatitis B and Haemophilus influenzae type B glycoconjugate vaccines, have not been realized except in the most developed countries. The three reasons often cited to explain this problem include poor access to immunization services, the evolution of complex primary immunization schedules, and the additional expense associated with new vaccines, potentially depleting scarce resources. The establishment of the Children's Vaccine Initiative is an organized effort to improve immunization by both technological and organizational innovation. Simplification of the vaccination process can be achieved by developing new combination vaccines or reducing the number of immunizations with vaccines that stimulate protective immune responses. Improvements in the organization of efforts to immunize children will also enhance the prospects of protecting the world's children from infectious diseases. To achieve the goals articulated in the Declaration of New York, the issues of transition from the old to the new vaccines must be addressed. Research on vaccines and technological innovation at all levels will be required to achieve these goals.

Most communicable diseases are caused by infectious agents that are not visible to the naked eye, which led earlier societies to believe in miasmas and control by quarantine. Although microscopes revealed the agents in the eighteenth century, they were not associated with disease syndromes until the late nineteeth century. Today, vaccines are the most cost-effective means of control.

As part of a restructuring program at a large, acute care hospital, a new, collaborative form of clinical management called triads has been initiated. Members of these collaborative management teams are being collectively empowered to better enable them to establish a continuously improving, cost-effective clinical service. This article describes the impact of this new structure on the capital budgeting process in changing a centralized, committee-based system of decision making with limited clinical nursing input to one that is increasingly decentralized, interdisciplinary, and focused on patients.

This article presents a preliminary and necessarily tentative and subjective assessment of the impact of new gene technology on health care costs. In the short term, diagnosis and treatment of genetic disease are likely to increase costs. Treatment with nongene therapy will continue to be far less expensive than gene therapy where it is available. Research developments to monitor as indicators of forthcoming cost reductions in genetic therapy are set forth. Some forms of genetic screening may soon reduce health care costs, and an example is provided. Genetically engineered Pharmaceuticals are described and their impact on costs reviewed. Conditions under which they are likely to reduce health care costs are indicated.

To determine the cost-effectiveness of colorectal cancer screening strategies in Japan and to determine the influence of long-term compliance with screening programs on the selection of strategies, the natural history of a simulated cohort of 40-year-old Japanese of both genders was modeled with and without colorectal cancer screening until age 75 years. Survival, number of complications, and direct medical costs were compared among several combinations of screening examinations. In addition, the age of initiating screening was varied, as was the long-term compliance rate. Strategies using immunoiogical fecal occult blood test were found to be the most cost-effective. Immunological fecal occult blood test followed by colonoscopy, if positive, would save 24.05 (5.88 discounted) days of life and cost 28,420 yen (US $210) per screened person, thus offering a cost-effectiveness ratio of 1.765 million yen (US $13,100) per year of life saved. If long-term compliance is 100%, initiating screening at age 40 years offers more years of life saved and a low incremental cost of screening. However, if more likely dropout rates are considered, initiation at age 40 years is dominated by later initiation of screening.

Does increased spending improve health outcomes? We analyzed 1988 data from OECD countries to determine how key health care indexes correlate with health care outcomes. Total health care spending per capita and outpatient and inpatient utilization are not related to health outcomes. How our resources are allocated seems to be more important than how much money is actually spent.

Much of the current interest in genetics stems from the Human Genome Project. Although the project will accelerate the identification of disease-related genes, as currently formulated it may retard discovery of gene function and effective treatments, thereby prolonging the stage in which people at risk of genetic diseases can be identified but not treated. This stage is fraught with ethical problems. The project's goal of sequencing the entire human genome could also detract from basic biological research, as could the growing interest of universities in biotechnology transfer to the commercial sector.

Traditional software development methodologies enhanced by a clinical component result in information systems that support the practice of nursing. This paper describes the clinical informatics model used to develop and evaluate a mobile computer assessment tool. Data entry of atomic-level elements, with storage in a relational database, allows the synthesis and analysis by multiple disciplines to aid in real-time decision making. The system is designed to improve the recording and accessibility of patient data and nursing observations on a geriatric unit at the Salt Lake VA Medical Center.

Immunization received intensive support during the 1980s in light of its demonstrable value, relatively low cost, and established infrastructure. The goal of universal childhood immunization was achieved in 1990 on the basis of a strategy of expanding coverage, technological improvements, and social mobilization. Although its impact is difficult to quantify precisely, the Expanded Programme on Immunization (EPI) has had significant positive effects on national and household economies as a result of the reduction of morbidity and mortality. It also has contributed to the development of the managerial and operational capacity of health systems and to the generation of widespread social and political support for health actions through a variety of different mechanisms. Priorities for the next decade include attention to policies to ensure the maintenance of high levels of coverage, continued technical development, and further strengthening of EPI planning and management.

In Japan, a nationwide mass screening system for neonatal metabolic diseases was established in 1977. This system consisted of screening programs for five main congenital metabolic diseases, including phenylketonuria (PKU). To evaluate the efficiency of the mass screening system, a costbenefit analysis of the screening program for PKU (as a typical case in Japan) was carried out. The costs of the detection and the treatment program were compared with the projected benefit (avoided costs) that results from prevention of the mental retardation associated with the disorders due to PKU. Costs and benefits were discounted at an annual rate of 7%. Assuming that the incidence of PKU was 1/80,500 and the total number of infants screened was 1.2 million, net benefits for the screening program were $283,000, and the cost-benefit ratio was 1:2.5. The sensitivity analysis for the incidence of PKU showed that the cost-benefit ratios exceeded one.

Assessment of the impact of genetic technologies requires an understanding of the ethical issues that such technologies raise, which in turn requires an understanding of the social context of genetics. This article discusses 10 factors that characterize the social context of contemporary genetics, and considers two presumptions that usually are unquestioned—first, that more choice is always better; second, that what can be improved should be improved. Recent experience with genetic screening and testing to increase reproductive choice indicates that it is sometimes an ambiguous good. Prenatal testing, which has been guided by an ideology of nondirective counseling, will become increasingly problematic as the menu of possible genetic tests grows longer, because nondirectiveness offers no way to distinguish between significant disease and parental whim. In the realm of reproduction, more choice may also come to mean increasing parental responsibility to have genetically “healthy” offspring. Technologies intended to improve health outcomes may also be used for non-health-related goals—such as to increase athletic performance or to capitalize on social prejudices. Genetic technologies increasingly will challenge the troubled distinction between therapy and enhancement.

As a new global strategy for improving public health, the Children's Vaccine Initiative implicitly raises, once again, the question of the role of science in developing countries. If there are to be new and improved vaccines, better delivery systems, and simplified immunization schedules, there must be substantial analysis, laboratory activity, and fieldwork to ensure that the new products are ready for effective use. In the context of these requirements, this paper reviews the possibilities for vaccine research and development in middle-income countries and the benefits in terms of fostering socioeconomic development through integrated scientific health research.

Planning for a cost-effective mix of providers is an important aspect of health care reform. Currently, there are too many specialists and insufficient numbers of primary care providers. Nurses in advanced practice roles are an important resource for expanding the nation's supply of primary care providers.