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Cytotec: Dangerous experiment or panacea?

Doctors are prescribing an unapproved, unpredictable ulcer drug to induce labor in thousands of women. Why are women the last to know?

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Cytotec: Dangerous experiment or panacea?

On Nov. 12, 1998, a week before her sixth baby was due, Holly’s nurse-midwife agreed to induce her labor. While there were no medical reasons for induction — one of Holly’s five daughters had weighed 9 pounds 4 ounces and had been born after only five minutes — the nurse-midwife contends that Holly complained of being tired of being pregnant. Before consenting to the induction, Holly’s midwife says, she asked one of the obstetricians in her group practice if Holly would be a good candidate to try a new induction drug. He approved the prescription.

Holly disputes her midwife’s story, asserting that the midwife recommended induction against Holly’s better judgment. “My body was made to have babies,” she told me. With five vaginal births to her credit, Holly had confidence in her ability to labor.

Whatever the truth, both parties agree that over the next several hours the nurse-midwife gave Holly three 25-microgram doses of Cytotec. (Because of legal considerations, both parties requested anonymity.) What Holly didn’t know and the midwife never told her was that it was an unapproved drug with potentially disastrous side effects.

One hour after the third dose, labor began, with contractions every two and a half minutes. According to Holly’s 19-year-old daughter, Ann, who was present throughout labor, Holly handled herself very well.

Thirty hours later, her cervix not yet fully open, Holly stood up and walked around. Then her bag of water broke. A little later she heard a popping sound from her body. The midwife monitoring her labor noticed that the baby’s heart rate had dived from a normal 130-140 beats to a frightening 40 beats per minute.

She exhorted Holly to push, and within five minutes, Holly’s 8-pound, 13-ounce daughter was born, followed by a huge gush of blood. The baby was blue and didn’t breathe on her own, so the resuscitation team intubated her.

Holly, meanwhile, continued to bleed. Frightened, she told her midwife that something was wrong. The midwife assured her that her blood loss was not enough to warrant a doctor’s presence. Later, realizing that Holly was bleeding excessively, the midwife removed several huge clots from her vagina, gave her medication to stop the bleeding and left her in the care of nurses.

Ann and Darryl, Holly’s husband, were far from reassured. By this time, Holly lay unconscious, white as a ghost. They helplessly watched her struggle for breath. Darryl begged the nurses to get a doctor and the midwife directed a nurse to call for a doctor on the intercom. The physician who entered the birth room two minutes later was shocked at Holly’s condition. “This lady is dying,” he shouted. “I’m taking her to the O.R.!”

Holly’s heart stopped twice during the surgery. At one point, the doctor told Darryl that he did not expect her to survive. Her uterus had ruptured from the top down through the cervix. This kind of wound is characteristic of Cytotec-related ruptures, according to obstetricians I’ve since spoken to. (One doctor described them to me as “totally exploding.”) Surgeons removed Holly’s uterus along with one of her ovaries and a fallopian tube. Thirty-seven units of blood, plasma and platelets were required to replace the blood lost during her ordeal. Gone forever was her chance to have another baby.

Was Holly’s labor a nightmare fated to happen, with or without intervention? Or did Cytotec cause her uterine rupture, thereby threatening her and her daughter’s life? As with so many forms of obstetric intervention, even hindsight isn’t 20/20. Every birth is unique, and the influences on labor are far more numerous than most studies can account for. And even with large, long-term, controlled studies, it is sometimes complicated to ferret out the facts about the efficacy or safety of a given medical procedure.

Cytotec, however, doesn’t have the benefit of such scientific debate, because it is still essentially an experimental birth drug that is being tested ad hoc by trial and error. But most patients are never informed of this fact.

As a midwife of 30 years and one of the founders of the natural childbirth movement, I have overseen more than 2,000 births at my birthing center in Summertown, Tenn. Over the years I’ve listened to innumerable anecdotes about the dangers of medical intervention. But the stories I was hearing about Cytotec I found especially unsettling.

Over the past three years I have watched in increasing dismay as this once little-known ulcer medication has become a popular obstetric drug — one with potentially horrifying side effects and a frightening lack of safety protocols. Buried in study after study, reports show that the drug has been connected to numerous cases of ruptured uteri and even a few maternal deaths, stillbirths and newborn deaths. Despite these reports, however, tales like Holly’s — in labors attended by practitioners who appear to have little understanding of the drug’s potential dangers — continued to reach me. In fact, the widespread use of Cytotec essentially amounts to a massive medical experiment carried out on thousands of unsuspecting women — a situation, sadly, that is all too common in the world of modern obstetrics.

Most Cytotec-induced labors do not cause adverse effects like those in Holly’s labor — in fact, for a significant number of women Cytotec seems to work amazingly well. In a way, that’s what scares me the most. Since it works so efficiently for a majority and can be prescribed obstetrically without Food and Drug Administration approval, there’s less motivation for learning why for some women the drug has a catastrophic effect. Aside from the oft-cited though widely ignored warnings against giving it to women who have had Caesarean sections, we know very little about which women are at risk.

What we do know about Cytotec is that it is dirt cheap: A single 25-mcg dose costs roughly 13 cents; Pitocin, in contrast, necessitates hundreds of dollars in high-tech intervention. Since Cytotec is made in 100-mcg tablets to be taken orally, its quarter-tab dosages are necessarily inaccurate: Nurses or doctors have to literally cut up the pills with little knives. Furthermore, there is still no agreement as to the dosage size or interval or even most appropriate route of administration. The most common means of administration, by placing a quarter-tablet next to the cervix, is so easy that some doctors and midwives give the pills to women to take home and insert themselves. As a result, some women who experience emergency complications like Holly’s do so without a hospital staff to care for them.

Unlike a Pitocin drip, which has a half-life in the body of about 10 minutes and can easily be turned off if the woman responds to it violently, once Cytotec is administered, you can’t get it out and nobody knows its half-life. This gives Cytotec an unpredictable, stealthy quality. Sometimes even when it is doing serious damage to the uterus, the woman has no awareness that something’s wrong; other times it creates immediate violent contractions. Moreover, the ruptures can occur many hours after a single dose in which the drug seemed to have caused no adverse effects. No one understands how this works, but it has been the subject of discussion both in the medical literature and in physician chat rooms.

Finally, in an era of managed-care obstetrics in which doctors are seeing patients in their offices at the same time that they monitor other women’s labors across town in the hospital by telephone, Cytotec’s great claim to fame — prompt, timely labors — is a phenomenal boon. In most cases an obstetrician must be present at the time the baby is born to be paid in full for a birth. So financial factors may influence some doctors to induce labor at a convenient time. Moreover, most cases of malpractice litigation involve situations in which doctors were not present and an adverse outcome occurred. Hence doctors have ulterior motives for using drugs like Cytotec, which help speed labor and thereby ensure that they won’t miss the big event.

How many women are being given Cytotec? Marsden Wagner, a Washington, D.C., perinatal epidemiologist, estimates that every year at least 150,000 U.S. women (about 3 percent of all births) are given Cytotec to start labor. But based on my conversations with other doctors and nurses, I sense that the number may be much higher. Its usage is certainly growing rapidly. Wagner also notes that the Oregon State Health Department recently told him that Cytotec is now the state’s most common method of induction.

How did Cytotec become so widely used and yet remain so underresearched? In 1992 and 1993 the first reports of the obstetric use of the small white tablet — generically known as misoprostol — indicated that it could be highly effective for starting labor in women, whether or not their cervixes were ripe. (In contrast Pitocin, the most common induction drug, often doesn’t work unless the cervix is already primed and therefore affords doctors fewer choices.) Cytotec had already been used in combination with other drugs as a chemical abortive — why not use it as an induction medicine? Lacking other information, many physicians began incorporating it into their practices.

A few years passed before the first published reports appeared detailing Cytotec’s adverse effects on labor induction. By then, word of mouth in medical circles had made Cytotec the new darling of American obstetrics. Cost-effective, quick and easy to administer, Cytotec was fast becoming a popular alternative to Pitocin, which requires a full high-tech approach, including I.V., continual fetal monitoring and often (because of its reputation for triggering especially painful contractions) an epidural. Cytotec, in contrast, can be administered (though it shouldn’t be) in virtually any setting.

Just how many women have been hurt by Cytotec? The question is nearly impossible to answer. No one has done large-scale studies of the drug, and the doctors and midwives who administer it do so with such vastly different protocols that mixing and matching results from various studies would not render reliable data. The most rigorous scientific authority in English on the effects of healthcare, the Cochrane Library, cautions that too few well-designed studies have been carried out to assess the risk factors associated with using Cytotec for labor induction. While conceding that Cytotec is more effective than conventional methods of cervical ripening and labor induction, it cautions that “the apparent increase in uterine hyperstimulation is of concern.”

Unable to find large-scale, comprehensive reporting on obstetric use of the drug, I decided to do a little statistical sleuthing (however unscientific) on my own. My research, and my gut sense, based on years of experience as a midwife, indicate that there are significant risks associated with Cytotec, certainly higher risks than those associated with other forms of induction like Pitocin. Combining the results in 20 studies of Cytotec-induced labors published in peer-reviewed journals and papers presented at professional meetings — a total of 1,958 births — I discovered a total of two maternal deaths, 16 baby deaths, 19 uterine ruptures and two life-threatening hysterectomies.

To make sense of these figures, consider the normal incidence of uterine rupture, the most common serious side effect of Cytotec. Uterine rupture virtually never occurs in spontaneous (unaugmented) labor in women who’ve had no previous uterine surgery. Probably because of differing practices surrounding labor induction and augmentation, the rate of uterine rupture varies widely from hospital to hospital. Uterine rupture is less likely to happen in an out-of-hospital birth. Most midwives providing these services do not use drugs to augment labor. The complication has been reported as frequently as one in every 100 births and as rarely as one in every 11,000 births. In my own group practice at the Farm Midwifery Center in Summertown, Tenn., in approximately 2,100 births we have had no uterine ruptures.

By contrast, approximately one in 100 Cytotec-induced births in the 20 studies I looked at resulted in uterine rupture. About half occurred in women having vaginal birth after Caesarean, the others among women who had had no previous uterine surgery.

In fact, it is women who have had Caesareans who are at greatest risk from Cytotec. An article published in 1999 in the American Journal of Obstetrics and Gynecology reported that uterine rupture occurred in five of 89 women with previous Caesarean delivery whose labors were induced with Cytotec — about one out of 16, a shockingly high figure, representing a more than 28-fold increase over those who did not have Cytotec induction for VBAC (vaginal birth after Caesarean). One of the five ruptures also caused a baby to die.

According to epidemiologist Wagner, “It can be reliably estimated that between 1990 and 1999, as a result of the widespread off-label use of Cytotec for vaginal birth after Caesarean section, well over 3,000 women in the United States suffered a ruptured uterus, resulting in at least 100 dead newborn babies.”

Amniotic fluid embolism, or AFE, is perhaps the most frightening complication associated with powerful labor-inducing drugs like Cytotec and Pitocin. AFE, which occurs when the amniotic fluid enters the mother’s bloodstream, is one of the most dangerous complications that can happen in birth. More than 60 percent of women and their babies die when it occurs, with survivors usually suffering neurological impairment.

The rate of occurrence of AFE, once thought to occur only once in 80,000 births, seems to be rising in the United States. Chicago writer Deanna Isaacs, whose daughter died from AFE in 1994, found that the incidence of AFE at the Phoenix, Ariz., hospital where her daughter died in labor was 1 in only 6,500 births. AFE is now one of the leading causes of maternal death in the United States. Two cases of fatal AFE are associated in the medical literature with the use of Cytotec; a midwife told me about a third.

Alarmingly high as these figures are, they almost certainly don’t reflect all of the adverse outcomes associated with Cytotec. I also gathered information — much of it hair-raising — from Internet chat-room discussions involving physicians who signed their names to their comments, as well as from obstetricians and midwives. This is anecdotal evidence, yes. But we can’t afford to ignore anecdotes because current medical studies are inadequate, the drug has not been subject to FDA approval and mothers’ and infants’ lives are at stake.

The enthusiastic discussion of Cytotec in medical chat rooms sheds light on why the drug has become so popular in the United States. “You can almost count on a delivery 12 hours after inserting the Cytotec tablet,” said one doctor. Another doctor added a cautionary note: “I must say that I have heard some great things about Cytotec myself. I know some people who have used it and say that they have pretty good luck with it. It sounds like your ladies are pretty happy with its effects — two-hour labors and such. Just be careful. I would have to say that the biggest danger is leaving the woman alone. The stuff turns the cervix to complete MUSHIE [emphasis in original] and opens it with a couple of contractions. So whatever you do, remember that you must not stay gone too long.”

Over the past 30 years, I have watched as wave after wave of medical fads have washed over the institution of modern childbirth. But one thing, unfortunately, hasn’t changed: The push to discover a panacea to cure the pain and inconvenience of childbirth drives doctors to experiment — and the women are usually the last to know.

In this case, to be sure, the demands of the women themselves are part of the problem. The Cytotec controversy is inextricably tied up with the increasing rate of induced labor in the U.S. Until fairly recently, induced labors were fairly rare: Now, one birth in five is induced, with only a small percentage of these inductions being medically necessary. Harried doctors in the HMO age are driving some of this, but women, too, are demanding faster labors. (This is not surprising, considering that the United States has the shortest maternity leave in the industrialized world.) If this trend increases, we can expect to see an accompanying rise in the medical problems that result when the strongest muscle in the human body — which is also paper thin — is stimulated to contract violently.

How was it that Cytotec came to be used as an obstetric drug in the first place? Misoprostol was originally developed by G.D. Searle & Co. of Chicago to prevent gastric ulcers in people who take anti-inflammatory drugs such as aspirin for arthritis pain. In 1988, it was approved by the FDA solely for this use. Yet it is quite legal for physicians to prescribe drugs for indications other than those for which the drug has received FDA approval.

This common practice, known as “off-label” use, usually involves prescribing one drug for another purpose. (Incidentally, no such loopholes exist for the use of pharmaceutical drugs in most Western European countries.) With misoprostol the practice seems particularly egregious: taking a medication meant for oral ingestion and inserting it vaginally.

According to Claudia Kovitz, public affairs specialist for Searle, the company does not intend to apply for FDA approval of Cytotec’s use in starting labor. Indeed, why should it? At 13 cents a dose, with women taking no more than three doses per birth, the drug is too cost-effective to waste a heap of money on research whose primary result might only be to make the drug illegal to prescribe.

So what protection do pregnant women have when it comes to drugs that are prescribed for another purpose? Very little, according to Laura Bradbard, spokeswoman for the FDA. “People think we have more authority than we have. We approve a product for a particular indication, based on the data we receive. A physician is free to use a drug for any use he or she feels will benefit a patient. There are no safe drugs. You need to do your homework, ask a lot of questions and speak with your physician about your case and the medications,” Bradbard said.

And even when the FDA approves a drug, there are no guarantees. “Once a drug reaches the marketplace, that’s when we find out all the adverse events, because we have only seen it in 3,000 to 6,000 people perhaps,” said Bradbard. “Then it goes into the marketplace, where you have a million prescriptions. Then a reporter will say to me, ‘You are approving things too fast. You didn’t find it.’ Well, we can’t find it. It’s mathematically impossible. We have to have it in the marketplace and then we have to make warnings.”

But Holly and her husband, like most patients who receive Cytotec, never received any warning. “We didn’t know it wasn’t FDA approved,” she said. “We would have never let them use me or my baby as guinea pigs.”

Whitman’s lesson for Romney

Layoffs at Hewlett-Packard show why business leaders aren't automatically a good fit for the White House

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Whitman's lesson for RomneyMitt Romney and Meg Whitman (Credit: AP/Chris Carlson)

When Meg Whitman ran for governor of California in 2010, the former eBay CEO told voters that her business background made her the right choice to boost job creation in a state troubled by high unemployment. Sound familiar? It’s the same spiel we hear from Mitt Romney every single day.

As a consolation prize for getting clobbered by Jerry Brown in the gubernatorial election, Whitman landed a plum job of her own — CEO of Hewlett-Packard, a company that, like California, has been going through some tough times. But this week Whitman made clear that as a business leader, her approach to job creation doesn’t quite mesh with her political promises. Multiple media outlets are reporting that HP is planning to cut its workforce by around 30,000 jobs — a number that accounts for 7-8 percent of HP’s total workforce.

Whitman’s decision will probably result in some layoffs in California, but it wouldn’t be fair to label her an outright hypocrite on the basis of this strategy alone. Downsizing may well be the right course for Hewlett-Packard, which is having a hard time adjusting to an era where computing is moving to the smartphone and leaving the PC far behind. But there’s a data point in the New York Times’ report on the layoffs that deserves close attention: “China, which is one of H.P.’s highest growth areas, will probably be spared.”

Again, this makes strict bottom-line sense. Hewlett Packard, by its own admission, now derives around 60 percent of its revenues from overseas. China is the world’s fastest-growing market for computer gizmos. Cutting staff in China would be suicidal. And HP’s behavior is in no way extraordinary. In April, the Wall Street Journal reported that between 2009 and 2011, fully three-quarters of the new jobs created at the 35 largest U.S. multinationals were overseas. And this isn’t just about offshoring to cheaper labor. Overseas is where the demand is.

The job creation plan outlined by Whitman when she ran for governor included cutting red tape, lowering various government fees, and tax breaks. Again, it’s an agenda that maps quite closely to Romney’s — and that’s no accident: Whitman was Romney’s finance chair during his 2008 campaign, and hosted a California fundraiser for him in March. But while cutting regulations may boost corporate profits,  it doesn’t do a darn thing for boosting demand. HP is probably more likely to take the money saved via a tax break and spend it on a new R&D center in Shanghai than it is to staff up in Silicon Valley.

All of this explains why having an illustrious business resume doesn’t mean that one is automatically qualified to occupy the White House in a time of economic stress. Business executives have a mandate to act in their own self-interest — to seek profit by any means, including  downsizing in the U.S. and pouring resources into China. That’s why HP’s “Government Affairs” page stresses its support for ” free trade and the reduction of barriers across borders,” even in the face of growing evidence that outsourcing to China has a negative impact on U.S. job creation.

A political leader is supposed to think in terms of the larger public interest — which means things like figuring out how to fund education or pay for the social welfare net that protects the unemployed and feeds the hungry. California’s voters figured that out when they rejected Whitman. Once again, it will be interesting to see where the general public at large comes down in the case of Romney.

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Andrew Leonard

Andrew Leonard is a staff writer at Salon. On Twitter, @koxinga21.

David Brooks, “structuralist”

The New York Times moderate says the welfare state is unsustainable, and buys himself a new $4 million home

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David Brooks,

David Brooks is everything that’s wrong with elite opinion in America. The president reads him and takes him seriously. That is why the opinions of venal faux “reasonable” clowns like Brooks matter. Brooks today sums up the new argument for not actually doing anything to alleviate worldwide unnecessary hardship: The problem is “structural,” not “cyclical”!

Long Op-Ed short, Brooks says “cyclicalists” (unnamed) think we should deficit-spend our way to prosperity, because, according to Brooks, they believe that “the level of government spending is the main factor in determining how fast an economy grows.” (No one actually believes this.) But according to Brooks, all of our problems are “structural,” which is to say that the reason we have mass unemployment and debt and growing wealth disparity is because of “technological change” and crappy schools. And “special-interest deals” in the tax code.

The point of the Brooks argument is simply to make continued non-action to address actual short-term pressing problems sound serious and wise. He’s not even making a partisan argument, you see. Oh, people on “the left” have been having their silly little debate, but all the serious people — “some on the left but mostly in the center and on the right” — have accepted the sad truth, like Brooks. And Brooks is soberly explaining the situation. He is not at all responding to Paul Krugman, his fellow New York Times columnist, who has lately taken to fiercely rebutting arguments put forth by various unnamed “centrists” and “moderates” in his columns.

This is Brooks’ conclusion:

But you can only mask structural problems for so long. The whole thing has gone kablooey. The current model, in which we try to compensate for structural economic weakness with tax cuts and an unsustainable welfare state, simply cannot last. The old model is broken. The jig is up.

It’s so sad, but everyone will now just have to accept that social democracy is an impossibility. We have learned that “the old economic and welfare state model is unsustainable,” so shut up about your unemployment benefits running out and there being no jobs still. (Silly me, here I was thinking the recent massive international financial crisis actually exposed post-industrial capitalism as the “unsustainable” thing.)

Ezra Klein has the rather polite, policy-based response to Brooks’ argument: Essentially that even if Brooks is right about America’s structural problems needing to be addressed, we should still also give poor people money and indebted people relief and spend money on infrastructure improvements to prevent these structural problems from becoming even worse.

Dean Baker has the response in which it is pointed out that Brooks is full of predictable, repetitive shit. The “we have no jobs because of technology and also there are plenty of jobs but unemployed people have the wrong skills” line is as old as the Great Depression and there is no actual evidence for it. It’s just what people who want to sound serious while dismissing efforts to spend money on economic stimulus say.

Hey, let’s check out some recent real estate news at the Washington Post’s Reliable Source blog, for fun. Looks like a Mr. David Brooks just bought himself a $3.95 million home in Cleveland Park!

The New York Times op-ed columnist and wife Sarah are trading up — from their longtime home near Bethesda’s Burning Tree Club to a century-old (exquisitely renovated) five bedroom, four-and-a-half bath house in Cleveland Park. It includes a two-car garage, iron and stone fence, generous-sized porch and balcony, and what appear to be vast spaces for entertaining. The timing seems to have been right: After only a few days on the market, their old place (which also boasts five bedrooms) is under contract for $1.6 million.

Whoops, sorry about your welfare state collapsing, 12 million out of work Americans, but it was just too “unsustainable” to keep you employed — you should all consider developing new skills and trying to find more “productive” work, like writing bullshit columns for the New York Times, maybe.

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Alex Pareene

Alex Pareene writes about politics for Salon and is the author of "The Rude Guide to Mitt." Email him at apareene@salon.com and follow him on Twitter @pareene

Bush vs. Obama: Jobs

During George W.'s first term, big government boosted employment. For Obama, it's the opposite

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Bush vs. Obama: JobsGeorge W. Bush and Barack Obama(Credit: Reuters/AP)

There is a number buried in today’s government labor report that deserves closer examination: 35,000. That’s the net number of private sector jobs created during the Obama administration to date. That’s right, it’s a positive number. After the worst economic disaster to befall the United States in 80 years, that’s a number that maybe we should be applauding. Remember: The private sector hemorrhaged more than 2 million jobs in the first three months of 2009 alone. The hole was deep.

Unfortunately, it’s still a tiny number, and it is dwarfed by a much larger figure: 607,000. That’s the number of public sector jobs — federal, state and local — that have been lost since Obama took office. It’s a story that probably isn’t getting told enough about the Obama administration: Big government keeps getting smaller.

But the real eye-opener comes when we compare Obama’s numbers to George W. Bush’s. In Bush’s first term, the economy shed 913,000 private sector jobs! 913,000! The only thing that saved Bush’s first term from being a complete economic disaster, in terms of employment, was robust public sector growth: The economy added 900,000 government jobs. One wonders: Without the massive growth in the public sector during Bush’s first term, would he have been reelected?

This is interesting for a number of reasons. First, it punches a big hole in the theory that Bush’s tax cuts were responsible for boosting employment during his first term. Let’s also recall that the Bush recession (which he inherited from Clinton) was far, far milder than the near-Depression Obama inherited from Bush. In that context, Obama’s performance resuscitating the private sector has been miraculous. The Washington Post published an article criticizing Obama for not doing enough to resist job losses in the public sector, without fully acknowledging the political impossibility of additional stimulus after the first round, but we haven’t heard all that much over the years about how the growth of government saved Bush’s bacon.

Of course, Obama isn’t running against Bush, so that’s moot. But as this presidential campaign heats up, it might be worth periodically reminding ourselves: Bush led the U.S. economy out of a weak recession with strong public sector growth. Obama is leading the U.S. economy out of a near-death experience while a steadily shrinking government swells the unemployment rolls. Which magic trick do you think is harder?

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Andrew Leonard

Andrew Leonard is a staff writer at Salon. On Twitter, @koxinga21.

Another jobs report downer

The U.S. economy underperforms again in April, creating only 115,000 jobs. You can almost hear Mitt Romney cackle

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Another jobs report downerJob seekers wait in line during a job fair in Portland, Ore., on April 24. (Credit: AP/Rick Bowmer)

The U.S. economy is stuck in spring mud. For the second month in a row, the United States labor market underperformed expectations. According to the Bureau of Labor Statistics, the economy created a lackluster 115,000 jobs in April. The unemployment rate fell one notch, to 8.1 percent, but for a distressing reason: The overall size of the U.S. labor force dropped by 342,000, a sign that hundreds of thousands of Americans simply gave up looking for work in April. The labor force participation rate fell to 63.6 percent, the lowest mark since 1981.

The only good news in the report: The numbers for February and March were both revised upward, from 240,000 to 259,000 in February, and from 120,000 to 154,000 in March. The economy is still growing.  Indeed, over the past 12 months, the U.S has added 1.8 million private sector jobs.

The glum report comes as little surprise. While economic data points were all over the map in April, some key indicators — jobless claims, Wednesday’s ADP private sector labor report, and the first estimate of GDP growth for the first quarter of 2012 — all suggested that the economic recovery that seemed so robust over the winter was losing steam. The numbers aren’t bad enough to justify outright panic; Americans are still lustily buying cars, the manufacturing sector appears strong, and gas prices are dropping steadily for their recent highs  – but it’s still very difficult to see signs of sustained momentum. This is the economy we’ve got right now. We can’t even blame austerity: Government payrolls dropped by only 15,000.

Ironically, on Thursday, Gallup’s presidential approval survey showed Obama at 51 percent, the highest mark he’s received since Seal Team Six took out Osama bin Laden. Conventional wisdom has assumed that Obama’s steadily improving approval ratings tracked the growing economy. If so, it will be interesting to see if those numbers start coming down again.

Mitt Romney, as one might expect, is already on the case. He promptly told Fox News that it was a “terrible job report.” That, strictly speaking, is not true. A “terrible” jobs report is one in which the economy loses half a million jobs or more in a single month — as was the case when Obama took office in 2009. (In fact, economist Justin Wolfers tweeted, April’s jobs report marks a milestone of sorts: Private sector job creation is, for the first time, in positive territory for the entirety of Obama’s term. Since January 2009, the private sector has added 35,000 jobs. The public sector, in contrast, has shed 607,000. So much for Big Government!)

April’s jobs report is disappointing, and could signal worse news to come, but there’s still a decent chance that we are just experiencing a bump in the road. By most measures, the U.S. economy is performing much better than it was a year ago.

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Andrew Leonard

Andrew Leonard is a staff writer at Salon. On Twitter, @koxinga21.

Healthcare’s foreign invasion

Obama risked a trade war with China about manufacturing -- so why isn't he outraged about medical jobs?

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Healthcare's foreign invasion (Credit: gualtiero boffi via Shutterstock/Salon)
This article was adapted from the new book, "Insourced", available May 8 from Dartmouth College Press.

Approximately 15 percent of all healthcare workers and 25 percent of all physicians in the United States were born and educated elsewhere. This means that 1.5 million healthcare jobs are “insourced,” occupied by foreign-born, foreign-trained workers brought into the United States on special visas earmarked for healthcare jobs. This number is 50 percent greater than the total number of jobs in the U.S. auto-manufacturing industry. It’s amazing to consider that in 2008 and 2009, the auto industry, which makes up just 3.6 percent of the U.S. economy, received a $97 billion bailout. If we estimate that each of these 1.5 million insourced healthcare jobs has an average wage of $60,000, that’s $90 billion a year in wages going to people brought into the United States to work rather than training Americans to do the same jobs.

The healthcare industry makes up 16 percent of our economy. Yet even in these days of close to 10 percent unemployment, we do not invest enough money in our young people to train them for jobs in healthcare — an already understaffed industry that will have to serve an additional 32 million people once the provisions of the 2010 health-reform law take full effect. Instead, when faced with pressure from hospitals and nursing homes for more healthcare workers, the federal government grants visas to import nurses, physicians, pharmacists, physical therapists, and many other types of healthcare workers from countries that can ill afford to lose them.

In some U.S. industries, the outcome of globalization is positive or neutral. Take the sugar industry. Due to lower labor and land costs and better weather conditions, it’s far cheaper to grow sugar cane in the Caribbean than sugar beets in North Dakota. As import taxes fall, global transportation improves, and the number of sugar beet farms in the United States declines, more Americans are sweetening their cereal with sugar from Jamaican sugar cane. Americans save money buying cheaper sugar; the economy of the poorer sugar-growing countries improves, lifting thousands of people out of poverty; and the few displaced American sugar beet farmers generally find other work. But sugar is not a strategic commodity. If CARICOM, the Caribbean Community, were to halt sugar exports to the United States, we would experience no crisis. Sugar is not essential to our diet or life, and we have plenty of substitutes, from honey and corn syrup to NutraSweet. If necessary, within a year we could again be producing sugar in the United States.

The U.S. healthcare industry is 200 times larger than the U.S. tire-manufacturing industry, yet President Obama risked a trade war with China, our biggest trade partner, over tires. He was understandably trying to protect well-paying manufacturing jobs for American workers. Yet each year, we bring thousands of nurses from China to work in even better-paying jobs rather than train young people in this country to become nurses. The irony is that the economic costs of “insourcing” healthcare workers, including the loss of jobs no longer available to Americans, are far greater than the costs when we import Chinese tires. In 2003 the Commission on Graduates of Foreign Nursing Schools (CGFNS), a U.S.-based nongovernmental organization that administers the U.S. nursing licensing exam for foreign-trained nurses, opened a testing center in Beijing. The opening of this center initiated a “mushrooming” of new nursing schools in China and led to credible predictions that China will soon surpass the Philippines as the number one source of foreign-trained nurses imported to the United States.

Given the publicity and furor over the loss of manufacturing jobs, the lack of protest over healthcare-worker insourcing is surprising. Congress passed legislation and President George W. Bush signed a law in 2007 to protect the American sock industry from the rival Honduran sock industry. Yes, that’s right: socks. Protecting a few hundred $15-an-hour sock-manufacturing jobs based solely in the small town of Fort Payne, Ala., was worth acting on. Yet insourcing hundreds of thousands of $60-an-hour healthcare jobs has prompted no such similarly high-level response from our leaders.

Instead, on a regular basis, Congress approves and presidents from both political parties sign legislation to enable the legal entry of an ever-increasing number of foreign healthcare workers. Each year, about 20,000 new healthcare-specific visas are issued for these workers.

The United States has traditionally not allowed strategic industries to be outsourced. That’s why the U.S. steel industry and the U.S. car industry have received bailout after bailout. Access to enough steel and automobiles is essential to our economy; without a sufficient supply of each, our economy would be severely damaged. It’s time we acknowledged that the health of the population is just as important as steel and autos in keeping our economy strong. Healthcare is too important to risk continuing to insource it.

It’s not just a matter of protecting and expanding jobs for American workers. Every year, thousands of Americans die, and the health of thousands more is compromised, because of the shortage of healthcare workers in every one of the healthcare professions.

On the surface, insourcing may appear to be a harmless or even win-win solution to the country’s healthcare-worker shortage. The hospital receives a much-needed worker, and the worker escapes life in a struggling country for a better life here. But we should be training more people in this country to work in those professions, especially people from poor and minority communities. Rather than investing in our own people and communities, however, the U.S. government has decided to take the best and brightest workers from struggling countries.

Many foreign-trained healthcare workers, no matter how smart, are not adequately prepared for practice in the fast-paced, high-tech world of U.S. medicine. Whether in operating rooms, hospital wards, or nursing homes, inadequately qualified and poorly oriented foreign healthcare workers endanger the lives of their patients, as well as the lives and careers of their American-trained colleagues.

But the main reason for this country’s rise in unnecessary deaths and delayed care is understaffing — a result of the failure to train and place enough healthcare workers, especially in rural and underserved communities. Americans who live in rural areas make fewer visits to healthcare providers and are less likely to receive preventive care. The infant-mortality rate for African-Americans is twice that for the average American; Latinos are twice as likely as white Americans to die from diabetes. These health disparities are due in large part to a lack of healthcare workers, especially primary-care workers, in their communities. The quick fix has been importing foreign healthcare workers for these unfilled positions. Unfortunately, once these workers fulfill their initial contracts, most move to communities without healthcare-worker shortages; in fact, foreign-trained healthcare workers are more likely to practice in the well-served, major metropolitan areas than their American-trained counterparts.

Even if good foreign-trained healthcare workers were here in numbers adequate to meet our needs, the U.S. healthcare system is about encounter a tidal wave of demand as 78 million baby boomers approach their 60s. Older people make, on average, six visits to a healthcare provider a year, compared with two visits per year for people under 60. The healthcare workforce is aging, too: More than 50 percent of practicing healthcare workers are eligible to retire during the next 10 years, which will leave us with fewer workers to treat more and sicker patients.

In the eyes of employers, of course, insourcing healthcare workers appears to offer many benefits. Most doctors and nurses in developing countries earn a fraction of what American doctors and nurses earn: A Caribbean nurse makes around $1,000 a month; an Ethiopian physician, about $100 a month. Not only are many foreign-trained healthcare workers accustomed to lower salaries and quality of life, but they also carry little or no education debt, while their American-trained colleagues typically graduate with five- and six-figure debt burdens. With average student debt burdens of $155,00011 for newly graduated physicians and $30,375 for nurses, American-trained health workers require a higher salary just to help pay for their education. Trained in a much more hierarchical environment, foreign workers are much less likely to unionize, or even express dissatisfaction with their work. As the percentage of imported healthcare workers increases, their attitudes toward salary and terms of employment undermine the bargaining power of U.S. workers, and even affect the important feedback loop between employees and management.

Polls indicate that 70 to 80 percent of Americans want to reduce the rate of immigration into the United States. Yet the American public is not aware of our policy of using healthcare-worker-specific visas to solve the healthcare-worker shortage.

Some legislators who publicly support stabilizing immigration consistently vote to increase the number of healthcare-worker-specific visas granted each year. It’s not that American citizens don’t want to become healthcare workers and fill these jobs. This distinction is critical, because every industry that has brought in foreign workers has argued that American workers won’t do the work for the prevailing wage, or won’t do the work no matter how high the pay is. In the healthcare industry, this argument does not apply. U.S. citizens want the jobs. They just can’t access the training. The United States does not have enough positions in health-professional schools to meet industry demands.

The tens of thousands of qualified nursing school and medical school applicants who are denied entry to school each year permanently lose out on their chosen careers, work that is consistently ranked in the top tier of salaries, with excellent benefits and almost guaranteed job security. This loss of career opportunity is even greater for rural and minority young people, who are grossly underrepresented in the higher-level health professions, such as physicians and nurses, and overrepresented in the lower-level professions, such as technicians and home health assistants. Something is wrong when so many young Americans are forced to pursue other, lower-paying careers at a time when we desperately need more healthcare providers. In exchange we get foreign healthcare workers who are less well trained (they consistently score lower on licensing exams than U.S.-trained healthcare workers) and far less culturally competent than native-born Americans.

The most tragic and most preventable effect of our hiring so many healthcare workers from other countries is the unnecessary deaths of hundreds of thousands of men, women and children in developing countries. The World Health Organization (WHO) estimates that each year more than 10 million people die needlessly, from easily treatable maladies such as diarrhea, pneumonia, malaria, tuberculosis, vaccine-preventable diseases, and complications of childbirth. The WHO Global Health Workforce Alliance estimates that there are a billion people alive today who will never see a health worker in their lives. In Ethiopia, one in 10 Ethiopian children will die before his or her fifth birthday — yet there are more Ethiopian physicians in the Chicago area than in all of Ethiopia, which, with 80 million people, is the second most populous country in Africa. As their most skilled nurses emigrate to work in U.S. nursing homes, middle-income countries such as Jamaica and Trinidad have nurse-vacancy rates of 60 percent or higher.

Throughout the developing world, nurses, pharmacists, physical therapists, and many other types of healthcare workers are being approached and offered 10 times their salaries to practice in modern U.S. healthcare facilities with state-of-the-art technologies. Even the most dedicated, socially conscious worker would be tempted by such an offer. A colleague of mine relayed a conversation he’d had with the head of the Nursing Council of Kenya, who told him about the damage the exodus of senior nurses was doing to her country’s healthcare system. In the next breath, she confessed that the next time he visited Kenya, she might not be there. She was thinking about emigrating herself.

Our unofficial policy of relying on the world’s poorest countries to pay for the training of workers whom we then entice and bring to this country is devastating healthcare systems around the world. The loss to a developing country when a single physician, representing what may be a significant portion of their total number of physicians, emigrates is far greater than our gain. Our failure to provide education for our own citizens and to better plan for healthcare staffing and distribution does not justify poaching nurses and physicians from the countries that can least afford to lose them. How many additional deaths, how much more needless disability and suffering, will we allow this misguided policy to cause?

And consider American competitiveness. Certain industries are vital to U.S. global leadership. Recognizing their importance, we protect those industries. We don’t allow them to move overseas and make the United States vulnerable to the actions of other countries. Poor farmers in the developing world can certainly grow food staples more cheaply than American farmers do. But because of the strategic importance of the U.S. food supply, we subsidize some basic food crops, such as corn and soybeans.

And yet we are overreliant on foreign healthcare workers to meet our most basic health needs. This is particularly dangerous because many countries, almost completely drained of healthcare workers and tired of subsidizing the U.S. healthcare system, are trying to slam the door shut for emigrating healthcare workers. Meantime, of the world’s wealthiest nations, the United States has the worst health outcomes, with lower life expectancies and higher rates of deaths from preventable causes. In infant mortality, for instance, we rank 27th, behind Poland and Hungary. Our disability levels are higher than in most former Soviet countries.

If the United States is to remain competitive in the global economy, we need a healthy workforce. In order to achieve that, we need a healthcare workforce made up of adequate numbers of properly trained physicians, nurses, pharmacists, community-health workers, and other healthcare providers.

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Dr. Kate Tulenko is a physician with degrees from Harvard University, Cambridge University and the Johns Hopkins School of Medicine. The former coordinator of the World Bank's Africa Health Workforce Program, she currently serves as director of clinical services for a global health nonprofit.

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