Healthcare Reform

Getting blown up, again and again

U.S. soldiers traumatized by Iraq are combating PTSD with a virtual reality treatment that plunges them back into the war zone.

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Getting blown up, again and again

Kevin Smith and his unit have just finished an unsuccessful search for snipers inside a house in Fallujah and are headed back to their base. Smith is behind the wheel of a Humvee, the seat beneath him vibrating from the familiar roaring engine. He makes a left turn and suddenly there is an ear-splitting boom, an explosion right behind him that rocks the vehicle. The sky goes dark and smoky, and Smith senses the piercing pain of shrapnel in his neck and hands. The Humvee’s radio crackles with voices asking for information, as his mind races. Will there be more explosions or a hail of bullets from unseen snipers? Are his fellow soldiers hurt? Time seems at once to speed up and slow to a crawl.

Then, just as suddenly, a voice cuts into the nightmare: “What are you thinking right now?”

It is the voice of Maryrose Gerardi, a psychologist at the Emory University School of Medicine and Smith’s guide through the world of “Virtual Iraq.” Smith isn’t actually in Fallujah, where he served as an Army infantry scout in 2004; it is April 2007, and he is in Gerardi’s office, wearing a sophisticated headset and sitting in a chair on a vibrating platform. Smith is one of a handful of Iraq veterans involved in the trial of a cutting-edge therapy that uses a high-tech virtual reality system to treat war veterans afflicted by post-traumatic stress disorder.

Smith, Gerardi and the designers of the virtual reality system say the experimental treatment has had such positive results that it may prove to be the most significant advance in years for the treatment of PTSD — a problem of growing scope among veterans returning from the wars in Iraq and Afghanistan. The treatment’s healing power derives from repeated exposure, using vivid simulation, to a veteran’s most traumatic memories of war.

For years, experts have considered exposure therapy, also known as talk therapy, to be the most effective treatment for PTSD: Doctors help their patients recall and confront troubling experiences, until the patients are habituated enough to control their emotional response. Virtual reality therapy is like exposure therapy on steroids. It plunges the patient into a direct sensory experience of past events, potentially accelerating the coping process.

As the veteran begins to recall an incident, a clinician introduces elements into the experience: A car bomb suddenly explodes, a building catches fire, insurgent snipers unleash a spray of bullets. “Virtual Iraq” resembles a video game, but it is also a convincing portrayal of the war zone, according to Smith. “It was like I was really sitting in the Humvee,” he says. “From behind the steering wheel, everything looked like what it really looked like there. The streets, driving down the road, the desert landscape, the mosques, the people, were realistic enough.” Other simulated sights and sounds include wind, a Muslim call to prayer, babies crying, footsteps, helicopters, rockets and gunfire. The veteran walks, stands or sits on the platform, which has a range of motion. The system, still under development, is also starting to incorporate smells, including gasoline, rotting trash, cordite, diesel fuel, spices and gunpowder.

Smith, whose real name has been withheld, recently finished participating in a five-week trial at Emory. He is one of eight Iraq veterans who have undergone the experimental treatment there; a handful of others have participated in virtual reality studies at military bases in California and Hawaii. Smith is the first Iraq veteran who has completed the treatment to speak about it publicly. He agreed to talk with Salon about his experiences both in Iraq and in the virtual reality treatment if his identity was kept private.

Smith was a 20-year-old college student living with his parents in Georgia when he joined the Army. He was deployed to Iraq in January 2004. Serving as an infantry scout meant Smith was either driving a Humvee or gunning — standing half-exposed in the turret, manning a .50-caliber machine gun. His days were a blur of firefights, of killing and the fear of being killed. He got little sleep, he says, often staying up for days during a mission, and returning to base for some sleep only to be awakened a few hours later for another mission. As Iraq spiraled into deeper chaos, he was constantly on guard against snipers, suicide bombers and roadside explosives.

“How do you feel right now?” Gerardi asks during the pause in the simulated ambush. Some soldiers become so upset or anxious that the therapist may have to shut off the program. “I’m OK,” Smith replies. In the beginning, Smith says the explosions and the sound of the radio going off made his heart race and his stress level quickly rise. “I started to get nervous and couldn’t really talk. I was mumbling but I didn’t even realize it at the time. Dr. Gerardi told me she couldn’t hear me.”

She asks him to rate his anxiety level on a scale of 1 to 100, a regular way of monitoring his response. Then he’s back behind the wheel of the Humvee, doing it all over again.

The goal, according to Gerardi, is to get a veteran to grapple with a selected memory at least twice if not three times in each one-hour virtual reality session. “With every repetition we get more details, and the memory becomes a more complete story. We want a narrative that makes sense and has all the sights and sounds,” she says. “But most important are the feelings that were happening at the time. In a survival situation you don’t have time to feel terror or grief about what is happening at that moment.”

That tends to come weeks, or even months, later. When Smith got back home to the United States in December 2004, he was plagued with nightmares, sleeplessness, irritability, jumpiness and depression. Terrifying thoughts of Iraq could enter his mind at any moment. Driving was difficult. “Bridges startled me,” he says. “Leaves blowing over the car. I was always looking for things on the side of the road.”

After several unsuccessful attempts to get effective treatment, Smith entered the virtual reality trial, and his fears finally began to diminish. “Every time I told the story, the less it bothered me,” Smith says. “For a long while I felt like I had done something wrong in Fallujah. They teach you in basic training that if you get shot, you did something wrong. They want you to be motivated. They tell you that if you die, it’s your fault. It was my Humvee and I was in control of it. I felt it was my fault.”

“He was very courageous,” says Gerardi. “He had some very difficult stuff to think about during the treatment. It was exhausting for him. It’s a very hard thing to do.”

Yet, despite Smith’s progress, some memories from Iraq are still too gruesome for him to confront.

When his unit first arrived in early 2004, Smith says Baghdad wasn’t terribly violent, and although there were occasional ambushes and roadside bomb explosions, it felt manageable. In late spring, he killed a person for the first time. It was then that he also first saw a dismembered body. “It was pretty traumatic,” says Smith. “Then things got worse. There was a lot of shooting, a lot of killing.”

Some of the experiences he survived “are too much for me,” he says. “I don’t want to relive them again.”

But it’s also clear that Smith is determined to win this protracted war within himself. He says that if his virtual reality treatment had continued for longer than five weeks — researchers are conducting 10-week trials at the military facilities in California and Hawaii — he would have attempted to confront other troubling memories. “Definitely certain scenes get me upset more than others,” he says. “One is when we shot up some insurgents in Fallujah, and one of the guys we shot didn’t die. He was pulling his brains out of his head. And I stood there and laughed at him. It’s just that we saw so many dead people. But afterwards, I felt like, holy shit, I just saw this and I laughed at it. I would think back on it, and it really disturbed me. Then it just gets in your dreams and you think about it every day.”

The cliché “war is hell” became true for Smith during one combat operation he refers to only as “the cemetery.”

In August 2004 his unit was sent to help quell an uprising in Najaf Cemetery in the city of the same name. One of the world’s largest graveyards, it is sacred to Shiite Muslims; millions are buried in its terrain, whose focal point is the shrine of Imam Ali, son-in-law of the prophet Muhammad. “It’s like no other cemetery you’ve ever seen,” says Smith, still struggling to discuss it. “The bodies are buried vertically and there are a lot of tombstones, like houses, and the cemetery went on for miles. We were in close combat, you’re getting shot at all the time. There were all these underground tunnels and it was August — like 120 degrees — and we were running around in these tunnels trying to find people. We were there for two weeks. It was one of the worst experiences of my life.”

Smith is one of the lucky ones. Many veterans of the war are suffering from PTSD and going without adequate treatment. In fact, mental health problems are the largest unmet need in veterans’ medical care, according to a recent study by Harvard economist Linda Bilmes. And the problem is growing: The Department of Veterans Affairs now estimates as many as 20 percent of those returning from Iraq suffer from PTSD, while a study released in March by the VA and researchers at University of California at San Francisco showed that nearly one-third of all veterans from Iraq and Afghanistan have some type of mental disorder. Yet, veterans must battle a sluggish bureaucracy to get help. A report from the Government Accountability Office released in March said VA officials estimated that follow-up appointments for veterans receiving care for PTSD may be “delayed up to 90 days.”

Those who do get access to mental health professionals often receive inadequate treatment, according to veterans and their advocates. Caregivers within the military system often tell veterans afflicted by PTSD that their problems are just “normal readjustment issues,” says Joy Ilem, who specializes in mental health issues as the assistant national legislative director of Disabled American Veterans. “These doctors need to be trained to recognize that symptoms that may seem physical in nature are not,” she says. “A lot of times there just isn’t adequate oversight, because the system is so massive.”

For the treatment of PTSD, both the Department of Defense and the VA’s clinical practice guidelines recommend exposure therapy, which includes eye movement desensitization and reprocessing, or EMDR, in which patients rapidly move their eyes while re-imagining a traumatic event. But many doctors stick to traditional psychotherapy, which typically doesn’t help vets confront traumatic memories. Or they just prescribe medications like sleeping pills, antidepressants and anti-anxiety drugs, and send them home.

Smith found himself on that tortuous path before finally getting effective help. He had gone to see a psychiatrist at Brooke Army Medical Center in Houston, while he was there recovering from his wounds from the Humvee ambush. “I talked to her a couple of times and then left. I think maybe she had seen too much of what I had and shrugged it off,” Smith says. “She didn’t seem to care much about it. She gave me some methods for coping, some stuff I should do to take my mind off it. But I didn’t get any actual treatment.”

For a while Smith even thought he might not have PTSD. But the symptoms persisted and got worse. He sought help again, this time closer to home, at a VA center in Georgia, where he returned after his release from the hospital. There he saw six or seven doctors, he says, and wound up with medication — sleeping pills and antidepressants — on which he is still dependent. But one doctor at the VA center also directed Smith to Emory’s virtual reality trial.

Virtual reality treatment is new for Iraq war vets, but its beginnings go back to 1997, when researchers at Georgia Tech released the first version of a more primitive program, called “Virtual Vietnam.” A study in 1998 found that even two decades after that war, symptoms of PTSD in Vietnam veterans were reduced by 34 percent when they were treated using the program. That prompted researchers at the Institute for Creative Technologies at University of Southern California to initiate a project in 2004 to create an even more immersive environment, using the latest technology.

Researchers at USC used the Xbox game “Full Spectrum Warrior” as a starting point, adding virtual elements, different scenery, motion and smell. One of the chief architects of the new system, research scientist and psychologist Albert “Skip” Rizzo, says that for people who haven’t been in combat, “Virtual Iraq” may look cartoonish — but to war veterans, who bring their own memories to the experience, it’s anything but a game. “With ‘Virtual Vietnam,’ we had a rice paddy and a helicopter. That was it. Soldiers would say, ‘I was being shot at by guys in the jungle’ and, ‘I could see the V.C. and there was a water buffalo.’ But none of that stuff was there. It was in their memory.” With “Virtual Iraq,” Rizzo says, the scenery is more complex and the entire experience more sensory, which draws out more details.

There are still some gaps: During the simulated Humvee attack, for example, Smith couldn’t look down while wearing the headset and literally see the knuckle on his hand blown off, or all the blood, or his injured comrades. But enveloped by the other sights and sounds, those details came alive again in his memory. “This process isn’t just about being exposed and sitting passively,” says Rizzo, “but talking about what you went through while you were there. Virtual reality serves as a prompt for that.”

Emory’s five-year study of the virtual reality treatment, begun this year, is funded by the National Institute of Mental Health and is open to any Iraq war veteran diagnosed with PTSD. It tests the effectiveness of virtual reality therapy in conjunction with a small dose, just prior to the session, of a medication usually used to treat tuberculosis: d-cycloserine. Taken before therapy, d-cycloserine can greatly reduce feelings of fear, researchers have found. But it is a “blind” study; Smith was put into one of three groups, so he doesn’t know if he received the d-cycloserine, Xanax (an anti-anxiety medication) or a placebo.

Smith says virtual reality therapy has been the best treatment he’s had so far. “I’m not as depressed. Talking to people is much easier. I’m less irritable, and I’m not as scared of the memories,” he says. Soon he will start seeing a psychiatrist for weekly exposure therapy sessions. “I think maybe then I’ll go over the Najaf memories,” he says. And he has since gone back to school and work, studying civil engineering and working part time at a Home Depot.

Initial results from the virtual reality treatment have been striking. “It’s still early so I don’t want to make grand claims,” Rizzo says, “but the results are excellent.” Four patients in the San Diego trial have completed treatment, and their last medical assessment indicated they no longer qualified for a diagnosis of PTSD, according to Rizzo. (One person completed treatment in San Diego with no benefit; that case is being examined. Two others started treatment and dropped out before completing it, which Rizzo says reflects the typical dropout rate for most forms of therapy.)

Barbara Rothbaum, director of the Trauma and Anxiety Recovery Program at Emory and the psychologist directing the “Virtual Iraq” study, has been treating PTSD since 1986. “I think this might be a powerful tool,” she says. “These guys seem to be doing very well in just five sessions.”

A non-military-related study of virtual reality therapy — being used to treat rescue workers involved in the attack on the World Trade Center — has also had promising results. JoAnn Difede, director of the Program for Anxiety and Traumatic Stress Studies at the Weill Medical College of Cornell University, recently published early results from the WTC study showing that after 14 weeks of virtual reality therapy, five out of eight subjects no longer met the criteria for PTSD.

Yet, as the number of Iraq war veterans with PTSD grows, virtual reality therapy is still rarely offered as an option. Neither the VA nor the Navy’s bureau of Medicine and Surgery, which is conducting the trials for the military, would comment on whether they plan to widen the trials or make it a treatment option for more veterans in the future.

Its advocates remain cautiously optimistic. “The idea was that we used the best technology to train soldiers and to conduct the war,” says Rizzo. “Now we need to draw on the best technology to make things right for these folks when they get home.”

Eilene Zimmerman is a journalist based in San Diego whose work has been published in national magazines and newspapers including The New York Times, Glamour, The San Francisco Chronicle, The Christian Science Monitor, CNNMoney.com, CBS MoneyWatch.com, Crain’s NY Business, Wired, Harper's, Slate.com and others. She writes the "Career Couch" column monthly in the New York Times Sunday Business section.

Romney pal defends Obamacare

Sen. Roy Blunt supports part of the bill his ally Mitt Romney has pledged to fully repeal

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Romney pal defends Obamacare(Credit: Reuters/ Jonathan Ernst)

Sen. Roy Blunt, R-Mo., gave a strong defense yesterday of a portion of the Affordable Care Act that allows children up to 26 years old to remain on their parents’ health insurance plans, breaking a bit from the GOP’s hard-line opposition to Obamacare.

Blunt endorsed Mitt Romney early on and led the campaign’s efforts to recruit Republican lawmakers during the GOP primary. But his comments in an interview on KTRS radio in St. Louis may give Boston some heartburn as it tries to convince conservative voters that Romney, who enacted the predecessor of Obamacare in Massachusetts, will actually repeal the healthcare law.

“It’s one of the things that I think should continue to be the case,” Blunt said of the “dependent coverage” provision, explaining that “it’s a way to get a significant number of the uninsured into an insurance group without much cost,” because young people are generally healthy.

Blunt noted that he even introduced a bill when he was in the House that would do exactly what the provision of the Affordable Care Act does now, saying, “I was for it then, and I’d be for it now.” “You’re breaking some news,” host McGraw Milhaven quipped.

While Blunt said he still favors repealing most of the health law, he would want to preserve a few sections, including the dependent coverage provision and the creation of high-risk pools for patients with preexisting conditions.

Romney has repeatedly vowed to fully repeal the Affordable Care Act, though he hasn’t spoken out specifically on the dependent coverage provision and he enacted a similar provision as governor. The provision is hugely popular, even though the overall law is not. And while Republican leaders supported the extension of coverage to 26-year-olds as recently as 2009, when it was included in the GOP’s healthcare alternative proposal, the GOP’s message today is that they’re for a complete repeal of the law, including the minimum coverage provision.

This got Sen. Scott Brown, R-Mass., in trouble after it was revealed that he takes advantage of Obamacare to make sure his daughter has insurance.

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Alex Seitz-Wald is Salon's political reporter. Email him at aseitz-wald@salon.com, and follow him on Twitter @aseitzwald.

“Birth control doesn’t matter”

A new survey reveals just how ignorant young people are about contraception and pregnancy

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(Credit: restyler via Shutterstock)

When it comes to sex and reproduction, even the most mind-numbingly intuitive conclusions can be politicized or disbelieved. So they bear repeating and resubstantiation. Take this recent Guttmacher study on contraceptive knowledge. Surveying 1,800 men and women ages 18–29, the authors “found that the lower the level of contraceptive knowledge among young women, the greater the likelihood that they expected to have unprotected sex in the next three months, behavior that puts them at risk for an unplanned pregnancy.” In other words, access to factual information helps prevent risky behavior.

I’m holding myself back from saying “duh” here, but this still has to be reiterated at a time when abstinence-only education that doesn’t provide detailed information about contraceptive use, except occasionally to emphasize its limits, not only persists but recently got a federal stamp of approval. As an Advocates for Youth report on the impact of abstinence-only education noted, “Proponents of abstinence-only programs believe that providing information about the health benefits of condoms or contraception contradicts their message of abstinence-only and undermines its impact. As such, abstinence-only programs provide no information about contraception beyond failure rates.” That’s how you get terrifying statistics like this one from the Guttmacher report: In the survey, “60 percent underestimated the effectiveness of oral contraceptives and 40 percent held the fatalistic view that using birth control does not matter.” Overall, “more than half of young men and a quarter of young women received low scores on contraceptive knowledge.” It’s also how you get figures like the one from the CDC that found that 31.4 percent of pregnant teens didn’t use contraception because they “thought they could not get pregnant at the time.”

There are two reasons to be optimistic that some dent can be made in these depressing figures, and they both have to do with provisions of the Affordable Care Act. Much has been made of the mandate that insurance policies cover all FDA-approved contraceptive methods, but there’s another aspect that’s been relatively overlooked: the fact that the same provision includes free education and counseling about sex and contraception, at least for the insured. The second reason for optimism is that the mandate will make it far easier for women to get longer-acting and more effective forms of contraception like the IUD — which are also more expensive and which studies have shown women would be interested in if they could afford them. Incidentally, the recent Guttmacher study found that women who were using long-acting or regular hormonal contraception tended to score higher on overall knowledge.

It will be awhile before we know if these changes will move the needle on the nation’s unparalleled rate of unintended pregnancy. The women’s health provisions only go into effect for new plans in August 2012, and older plans will be initially grandfathered and eventually phased out. And of course, there’s another big fat if – whether the Supreme Court overturns all or part of the Affordable Care Act. The Obama campaign and its allies are keen to point out how such a move — or, perhaps, a legislative repeal down the line — will hurt women above all. The Center for American Progress recently released a report on “Women and Obamacare” (the campaign having officially embraced the derisively intended term). It declares Obamacare “the greatest legislative advancement for women’s health in a generation,” which may be true for reasons more depressing than inspiring: There have been very few advancements partly because there has been so much political defense played.

In addition to the reproductive health benefits, the report points to preventive care recommendations for which cost-sharing has already been cut: mammograms, pap smears, prenatal care and so on. According to the report, “close to 9 million women will gain coverage for maternity care in the individual market starting in 2014,” currently not covered in 78 percent of plans sold on the individual market. It notes that women are more frequent users of healthcare services than men, that they’re likelier to make the household decisions on healthcare and that they’re more vulnerable to losing coverage because they’re likelier to be listed as dependents on a partner’s plan. The Affordable Care Act also makes it illegal to engage in “gender rating” – charging women $1 billion more than men on the individual market – and bans states from discriminating on the basis of gender identity in their insurance exchanges.

The report does acknowledge two ways in which Obamacare falls short for women who were “left out of the law — undocumented and recent immigrant women and women who need abortion services.” It claims that “political compromises on abortion coverage were necessary to ensure passage of the Affordable Care Act” – still a bitter loss to reproductive rights groups, who memorably described women as having been “thrown under the bus” by Democrats – “but the work to obtain abortion coverage for all women continues.” The last part is particularly debatable, at least when it comes to any momentum on the funding issue from national Democrats, while Republicans in the states and federally have spent considerable energy trying to limit abortion coverage on even private insurance plans.

Still, if the Affordable Care Act is allowed to stand, the magnitude of having an actual, proactive reproductive health access policy shouldn’t be underplayed. Maybe we’ll get closer to a saner republic where hearing “birth control doesn’t matter” from people who don’t want to get pregnant is a quaint memory.

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Irin Carmon

Irin Carmon is a staff writer for Salon. Follow her on Twitter at @irincarmon or email her at icarmon@salon.com.

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.

Obama destroys Constitution with mild Supreme Court criticism

Conservatives and moderates declare SCOTUS-bashing to be "intimidation"

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Obama destroys Constitution with mild Supreme Court criticism (Credit: AP)

Ruth Marcus is unsettled. Maybe even queasy. There is probably some light nausea. What has her worried for the future of the nation, today? President Obama’s shameful, horrific, vicious attacks on those nice people in the Supreme Court.

Obama said that the court overturning Congress’ healthcare reform law would be a textbook example of “judicial activism” as “conservative commentators” define it: “that an unelected group of people would somehow overturn a duly constituted and passed law.” And hey, that seems like an eminently defensible and not particularly unsettling point! Conservatives made “judicial activism” into a talking point and rallying cry and defined it vaguely enough to encompass judges striking down basically any law or statute.

Marcus, though, is stopped cold.

And yet, Obama’s assault on “an unelected group of people” stopped me cold. Because, as the former constitutional law professor certainly understands, it is the essence of our governmental system to vest in the court the ultimate power to decide the meaning of the constitution. Even if, as the president said, it means overturning “a duly constituted and passed law.”

Judicial review, as a former constitutional law professor certainly understands, is not in the Constitution — an unelected activist judge made it up! — and the founders themselves disagreed on the wisdom of the principle. (They tended, in fact, to decide whether or not they liked judicial review based on whether or not the judges ruled in a way that they approved of.) The history of the Supreme Court is replete with nakedly political and mostly conservative rulings until very recently, when we had a brief period of liberal-leaning rulings from a marginally more diverse group followed by a return to status quo conservatism.

As long as the Supreme Court has been making awful and indefensible rulings based on ideology or racism, presidents and politicians have been criticizing the court. Abraham Lincoln attacked the Supreme Court in his first inaugural address, in a passage that conservatives love to quote when they’re attacking “activist judges.”

At the same time the candid citizen must confess that if the policy of the government, upon vital questions, affecting the whole people, is to be irrevocably fixed by decisions of the Supreme Court, the instant they are made, in ordinary litigation between parties, in personal actions, the people will have ceased, to be their own rulers, having, to that extent, practically resigned their government, into the hands of that eminent tribunal.

I am stopped cold and unsettled!

Marcus, hilariously enough, supports the healthcare law and the mandate — she is the world’s most sensitive milquetoast moderate liberal newspaper columnist, after all — which theoretically means she thinks it’s constitutional, which would mean that declaring it unconstitutional should maybe upset her more than criticizing the court for being political, but on the other hand those judges seem very smart and our entire system of government could collapse if we aren’t all super polite to one another and constantly deferential to authority.

I would lament a ruling striking down the individual mandate, but I would not denounce it as conservative justices run amok. Listening to the arguments and reading the transcript, the justices struck me as a group wrestling with a legitimate, even difficult, constitutional question. For the president to imply that the only explanation for a constitutional conclusion contrary to his own would be out-of-control conservative justices does the court a disservice.

Yes, I could tell they were very seriously wrestling with a difficult constitutional question when Scalia began joking around about broccoli mandates and the legendary “Cornhusker Kickback.”

I’m not sure what more the Supreme Court could do before moderates like Ruth Marcus finally acknowledged that it’s a partisan body with a right-wing majority. If Bush v. Gore didn’t do it, maybe nothing could. But as a partisan body it is open to partisan attacks, and our fragile democracy will not descend into anarchy if people think as poorly of the Court as they currently do of Congress.

Of course, the Republican talking point is that the president is attempting to bully the Court into ruling the way he wants. (Because if they strike down the law, he’ll … yell at them during the State of the Union again? No one seriously predicts an arrest warrant for Chief Justice Roberts here.) Mitch McConnell: “This president’s attempt to intimidate the Supreme Court falls well beyond distasteful politics; it demonstrates a fundamental lack of respect for our system of checks and balances.” Lamar Smith: “What is unprecedented is for the president of the United States trying to intimidate the Supreme Court.” Mike Johanns: “”What President Obama is doing here isn’t right. It is threatening, it is intimidating.” (Did you notice how everyone used the word “intimidate”? That’s because they got their language from a memo.)

The only time, besides Lincoln’s suspension of habeas corpus, that any president has seriously threatened the independence of the Supreme Court was when Franklin Roosevelt tried to amend the law to give the president the power to appoint more justices. And Roosevelt, frankly, was right on the merits of his proposal. The court is completely unaccountable and ridiculously powerful, it always has been, and pointing that out does not a constitutional crisis provoke.

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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

My son’s healthcare battle

My 14-year-old has brain cancer. Without Obamacare, he would have already exceeded his lifetime insurance limit

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My son's healthcare battleSupporters of healthcare reform rally in front of the Supreme Court on the final day of arguments regarding the healthcare law signed by President Obama on March 28, 2012. (Credit: AP Photo/Charles Dharapak)
This originally appeared on Janine Urbaniak's Open Salon blog. It was written in a response to a call for essays about people's personal experiences with the Affordable Care Act. Have an Obamacare story of your own? Blog about it on Open Salon.

Mason is my 14-year-old son, who is adorable and funny, and happens to have a very stubborn and large brain tumor. We discovered the tumor four years ago, and we have been monitoring and treating it with the help of some of the finest doctors around. Mason has lived a somewhat “normal” life, despite frequent MRIs and even chemotherapy. He did his homework and hung out with friends until the fall of 2010 when his headaches became debilitating. Scans revealed that Mason’s tumor had grown for the first time since we had discovered it. Then days before we were scheduled to meet with the neurosurgeon to discuss a surgery we had tried to avoid, Mason had a massive cerebral hemorrhage.

My boy spent 65 days in the pediatric intensive care unit (PICU) at one of Northern California’s best hospitals; during that time he underwent two brain surgeries, along with operations to insert a tracheostomy and a feeding tube. We stayed with him 24 hours a day, my husband, Alan, and I, his grandparents, and his 16-year-old brother, watching his oxygen levels on a screen, tracking his heart rate in beats per minute. The doctors kept him sedated, but every morning they turned down the propofol (Michael Jackson’s drug of choice) when the neurosurgeons came to do their examination. Three to five doctors circled Mason’s bed, one of them yelled his name into his ear. When he didn’t wake up right away, they apologetically pinched him and yelled louder.

When I was alone with Mason I put a white earbud into his ear and tuned my iPod to a song I knew he liked, “Airplanes” by B.O.B. I said it was time to wake up. “You need to come back, now,” I told him in my firm mommy voice.

During our first three weeks of hospitalization Mason racked up $1.1 million in medical bills. I worried about butting up against the $5 million lifetime limit on Mason’s health insurance policy. We had a good policy with a good company.  We always paid our premiums on time and in full. But Mason wasn’t getting out of the hospital at any time soon, and there were months of rehab ahead. My then 13-year-old son would have reached his lifetime limit of health insurance had such limits not been eliminated by Obamacare on April 1, 2011. That date felt like a birthday or anniversary, something to be celebrated, when it finally arrived and we weren’t yet dropped by our health insurance company.

After two months in the PICU, we moved to a sunny room on one of the hospital’s regular floors. Our boy had just regained consciousness, though he still couldn’t talk or move his arms and legs. When the neurosurgeons came for their daily exam, we cheered when Mason managed a half-mast thumbs up. It was a huge victory.

As we celebrated our first day out of the pediatric ICU, Polly, the hospital discharge planner, introduced herself. Her job was to get the necessary approvals from our insurance company and make sure every moment of our stay was covered. This meant that she needed us to be ready to leave at any time. We needed a plan. She talked about Mason’s options for rehabilitation facilities. I soon realized that it would be challenging finding a place for a 6 foot tall 13year-old with a neurological injury. I scoured the Internet on my laptop for options.

A few days later, Polly stopped by to let me know that our insurance company representative had told her that Mason no longer needed hospitalization. Someone (she wasn’t naming names but they were clearly not a part of our medical team) suggested that we send our boy to an “interim” facility in a rundown city 40 miles away from our hospital and about 60 miles away from our home. I looked at Mason, who was enjoying his lunch through a feeding tube in his abdomen and breathing through another tube attached to a ventilator. I reminded her that Mason needed to be where he had access to neurosurgeons for emergencies. She smiled blankly and repeated something about medical necessity and pre-authorization. It was out of her hands.

Mason bought us a reprieve with a high temperature and a series of seizures.  It started when his eyes fluttered from left to right, then his body stiffened. I rang the emergency button and the nurse ran for the appropriate drug. I held Mason’s hand and told him we were riding a big wave. It was pulling us under but we would always emerge. It would pass. I kept my voice low and even.

When my husband arrived later that day, I told him that at least they were not going to kick us out of the hospital now. I was aware my thinking had taken on a new and undesirable twist.

I avoided Polly. If I saw her at the nurse’s station, I ducked back into Mason’s room and locked myself in the bathroom. If she called, I let her leave a message. I spent all of my time caring for my child. Did the nurse wash her hands when she came into the room? Had Mason received his 3 p.m. meds? It’s not that I wanted to spend any extra time in the hospital, it was just that Mason was still so fragile and we had nowhere to go yet.

The insurance company appointed one of their staff nurses to support us through our medical crisis. I believe she was a compassionate and concerned human being, but I never trusted her. I imagined that her notes would go into Mason’s file for the utilization department to examine and find reasons why they should cut back on his care, or lose him from their roles entirely. Any time she called, I heard the voice of Sgt. Joe Friday from Dragnet reminding me, “Anything you say can and will be used against you.”

Several people mentioned that TIRR in Houston was one of the best neuro-rehabilitation facilities in the U.S.  Footage of wounded Rep. Gabrielle Giffords arriving at TIRR was airing on every news channel. I don’t believe in coincidences, especially when thousands of people were praying for us. I called to see if TIRR was a part of our health insurance network. It was. It turned out that TIRR had expertise working with teenagers and there was excellent neurosurgical care available less than a mile away at Texas Children’s Hospital. It seemed like this was meant to be until Polly burst into our hospital room and told us that we couldn’t go. Though the insurance company approved the rehabilitation, they refused to pay for the air ambulance. We dipped into our savings, grateful that we could, and chartered our first airplane; this one came with a crew of paramedics.

The rehab doctors weaned Mason off of pain medication and fitted him for a wheelchair. He was out of bed every morning and dressed in sweat pants and a T-shirt. He began occupational, physical and speech therapy, though in the early days he often nodded off halfway through a session. A neuropsychologist said Mason’s prognosis was good. The healthy brain tissue had not been harmed by the hemorrhage. It was just a matter of getting the wiring back online in Mason’s brain, retraining his muscles and building his strength.

The insurance company rationed out Mason’s rehab approvals two weeks at a time. To meet their standards, Mason had to strike the balance between needing ongoing therapy and showing continued progress. If he stopped getting better, the insurance company would stop paying for his therapy, which presents a problem because brain injury patients typically hit plateaus in their recovery. I prayed daily for the faceless insurance company doctors who parsed out Mason’s approvals, wishing them insight and compassion.

A rehab hospital is not the place to visit if you want to pretend that awful things can’t happen to blameless people. In addition to stroke victims of all ages, there was a 30-year-old woman who was rear-ended at high speed on an interstate highway. Her mother brought her 2-month-old baby to visit whenever she could, though the young woman stared ahead her eyes not seeming to focus. There was a naval officer who suffered oxygen deprivation due to an illness he suffered on a ship somewhere in the Pacific. His mother brought me strawberries when she came to visit one Saturday. Then there were two other teenage boys, like Mason, with different varieties of brain tumors. One didn’t survive his stay, though I’m not sure what happened. The other walked out of the rehab to the cheers of his therapists and all the rest of us.

We never saw congresswoman Giffords, though I found the presence of the Secret Service reassuring. Nancy Pelosi toured the gym one afternoon when Mason was having physical therapy. I introduced myself. She smiled and complimented my beautiful boy who was walking in a harness mechanism. I meant to thank her for the healthcare bill, but it was too disorienting speaking to someone I usually watch on CNN. John Boehner didn’t stop by, maybe it was too much, seeing all these folks flaunting their preexisting conditions, exceeding their lifetime insurance limits with such brazen determination to pull themselves upright again.

P.S. Mason is back in school, finishing 8th grade. He is walking, talking and working out at the gym three times a week. He received an A- on his paper on “Of Mice and Men.”

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Janine is a San Francisco Bay Area writer. She is currently working on a collection of essays about surviving her son's brain tumor and the odd reality that comes with a diagnosis of childhood cancer.

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