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Online Pharmacies and Telemedicine

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Not a day goes by when our email inboxes do not fill with advertisements for prescription drugs. Many of these emails promise to deliver drugs of all classes by overnight courier without a prescription. While there are legitimate online pharmacies, and the practice of telemedicine or cyber-medicine is gaining acceptance, this change in the way medicine is being practiced is rocking the foundations of the medical establishment. Being able to consult a doctor online, and obtain prescription drugs delivered to your doorstep by UPS has broad social and legal implications. The Internet facilitates making drugs available to those who may not be able to afford to pay US prices, are embarrassed to see a doctor face-to-face, or are suffering from pain, the treatment of which puts most doctors in direct conflict with the ‘war on drugs’ but on the other hand there is the question whether these pharmacies make drugs available to recreational drug users without the oversight of a licensed medical practitioner.

The Need for Alternatives

Medical care in the US has reached a point where it is expensive and impersonal which has caused the consumer to become generally unsatisfied with the medical establishment as a whole. Examples include the huge differences between the cost of drugs in the US and Canada, long wait times in US pharmacies, and poor service in general. Perhaps realizing this, US customs appears to tolerate the millions of Americans that visit Canada every year to buy their medications, as for the most part, these ‘drug buyers’ are elderly American’s that can’t afford the high cost of filling their prescriptions in the US.

Rather than to travel to Canada or Mexico millions of Americans are now turning to the Internet for both their medical needs. Telemedicine (or cyber medicine) provides consumers with the ability to both consult with a doctor online and order drugs over the Internet at discounted prices. This has resulted in consumers turning to online pharmacies for their medical needs, and in particular pharmacies with a relationships with a physician, which allow the consumer to completely bypass the traditional brick and mortar pharmacies, with the added benefit of having their physician act as an intermediary between the consumer and the pharmacy. According to Johnson (2005) this is as a result of consumers becoming very dissatisfied when it comes to dealing with both brick and mortar pharmacies and medical practitioners. As Johnson, notes, “Consumers are more likely to know the name of their hairdresser than their pharmacist.” When Johnson (2005) rated the various professions within the health care system, he found that pharmacists had the lowest interaction with their patients than did any other group. Today, as a result of this “consumers are buying 25.5 percent of their prescriptions online, opposed to 13.5 percent of which are picked up at a brick and mortar pharmacy” (Johnson 2005).

Drugs and Society

What has brought so much attention to online pharmacies is that it is possible to obtain just about any drug without a prescription online. Many of these prescriptions are for legitimate purposes purchased through an online pharmacy because the buyer is too embarrassed to visit the doctor or for other reasons including the unavailability of FDA approved drugs to the consumer. These drugs may include steroids that due to their misuse and being classed as a classed a category three drugs, are seldom prescribed by physicians. These drugs have a useful purpose to those suffering from any wasting disease such as AIDS, they also play a role in ant-aging (FDA, 2004).

The Doctor Patient Relationship

Today a visit to a doctor is generally brief, much of the triage it is done by a nurse or a nurse practitioner with the doctor only dropping in for a few minutes, if at all. In many cases the patient is seen by a nurse practitioner. One of the arguments against telemedicine or perhaps a better term is cyber-medicine, is that the doctor does not have a physical relationship with the patients and thus is in no position to make a diagnosis, and thus can not legally prescribe drugs.

Ironically when one compares the work up that one has to go through to consult with an online physicians and compares this to a face-to-face visit with a brick and mortar doctor, one finds that the online physician, in many cases, has a better understanding of the patient’s medical condition than does the doctor who meets face-to-face with the patient. In most cases before an on-line a doctor prescribes any type of medication they insist on a full blood workup they may also require that one has additional tests performed, for example.

The AMA, the federal government, and various states claim, however, that it is illegal for a doctor to prescribe drugs without a valid doctor-patient relationship. While there are no laws at present that outlaw online pharmacies, various states have enacted legislation, or are in the process of enacting legislation to prohibit a doctor from prescribing drugs to a patient that they have not seen face to face. Some states also require that the doctor that prescribes the drugs be licensed in their state. This alone could hamper the development of cyber-medicine. According to William Hubbard (2004), FDA associate commissioner “The Food and Drug Administration says it is giving states first crack at legal action, though it will step in when states do not act” (FDA, 2004).

Internet Pharmacies

The reason that email boxes around the country fill up with offers to supply drugs of all kinds, at reduced prices, without prescriptions, and more is because people buy them as the billions of dollars the drug companies are making each year attest to. The Internet has become the drug store of choice for many.

Categories of Internet Pharmacies

Internet pharmacies are generally acknowledged to be comprised of the following five categories:

Internet pharmacies can be divided up into five different categories, as follows:

Licensed online pharmacies with a no medical affiliation.

Licensed online pharmacies with a medical affiliation

No record online pharmacies (NRP)

International online pharmacies (IOP)

Licensed compounding pharmacies

The licensed online pharmacies with a no medical affiliation are of course Drugstore.com, CVV, and others. They all require a prescription from a licensed doctor that the patient has a doctor patient relationship with. The prescription can be called in by the doctor.

The licensed online pharmacies with a medical affiliation often depend on a broker. The broker collects your medical information, and then assigns your case to one of their networked physicians. Many of these networked physicians are willing to prescribe pain killers as they believe that it is only through the use of these drugs that some people can live a harmonious life.

A Government Accountability Office (GAO) Committee on aging held in June 2004 found that “Unlicensed international pharmacies do not require a prescription, and are generally located off shore.” No prescription pharmacies can be found all over the world. Many of these sites have come under controversy as in some cases all it takes to have that prescription delivered to you by next day air, is to fill out a questionnaire online.

A study conducted by Henkle in 2002 to ascertain how easy it would be to obtain drugs over the Internet found that “37 of the 46″ pharmacy required a prescription from a licensed doctor. The emphasis was on the prescription and not on the doctor. Henkle (2002) in fact notes that some sites offered to recommend a doctor.” Henkle (2002) was able to obtain prescription drugs from nine sites outside the US during the study, without a prescription.

Online pharmacies with a doctor affiliation

There are a number of online pharmacies, with a medical affiliation is that take great pain to differentiate themselves form unlicensed overseas pharmacies. These pharmacies, stress that they are “American based companies that provides consumer’s easy access to FDA approved online prescriptions over the Internet and are quick to point out that “An online consultation can be just as relevant as an in-person consultation.” It is interesting to note that many of these online pharmacies also point out that “While they are committed to making access to online prescriptions easier, they believe that the Internet can not replace the importance of regular doctor visits to fully evaluate your health and any medical conditions.” Many of these online pharmacy sites also makes a wealth of drug information available on its web site that enables the consumer to educate themselves on drugs that may have been prescribed. The Internet has for all intensive purposes is quickly replacing the brick and mortar base physician as a patient’s primary health care provider.

A sales pitch, of course, or is it? Most of the legitimate online pharmacies ensure that they comply with state and federal regulation. The doctors are licensed in all 50 states and their pharmacies are too. These legitimate Internet pharmacies cater to those that are looking for a better price; for some it comes down to making the choice of eating cat food on crackers in order to afford their medications because of the high US drug prices. In other cases patients resort to cyber-medicine to avoid the embarrassment of having to deal with a physician or pharmacy that may be judgmental. Many of these online pharmacies will arrange a consult with a licensed, medical doctor over the phone and will then fill the prescription accordingly.

According to Henkel (2000) “More and more consumers are using the Internet for health reasons” and references a study carried out by a market research firm Cyber Dialogue Inc., “that found that “health concerns are the sixth most common reason people go online” (Henkel 2000).

For many people a trip to the pharmacy is an ordeal. In some cases the local pharmacy may also be located in the closest town which may mean a long drive if one lives in a rural community. Online pharmacies provide a means through which their prescriptions can be delivered conveniently and quickly. Being online also allows the consumer to shop for the best prices, an important factor if one is living on a pension.

The Internet has also created a more aware user. It is not unusual for a consumer to research drugs on the Internet. A consumer may have seen a TV or magazine advertisement advertising a new drug. Ultimately, the Internet also provides the consumer the opportunity to enter into a doctor patient relationship that may in fact be more legitimate than the doctor who makes a physical appearance. Further information on doctors that practice telemedicine can be found at: http://www.becomeone.com

It is interesting to note, as discussed previously, that consumers are becoming dissatisfied with the care and treatment they receive from both brick and mortar physicians and pharmacies. Zanf (2001), references a study by Lang and Fullerton that “Identified four factors related to outpatient pharmacy services: professional communication, physical and emotional comfort, demographics, and location and convenience.” All of which are contributing factors as to why more and more consumers are resorting to cyber-medicine.

The Dark Side

There is also a dark side to the Internet pharmacy, as previously discussed, spam email touting the availability of any prescription drug one could want, without a prescription, is something everyone is familiar with has reached epidemic proportions.

From Ambien, and of course Viagra to more powerful drugs such as Oxycontin, you can have it all. Over night shipping is available in most case, or so these emails proclaim.
In some instances this pharmacy spam originates from unscrupulous individuals who have no intention of delivering the drugs, realizing that very few people, if any, will complain about the non delivery of an illegal drug through the mail.

In other cases the drugs are sent without a prescription from countries where that particular drug may legally be sold without a prescription, or at least the laws are more relaxed. Valium, for example, is sold over-the-counter in Taiwan.

According to Crawford (2004) “Consumers who purchase drugs online thinking that they are they are getting the same drugs as they would from their local brick-and-mortar pharmacy are being misled, and as a result are putting their health, and eventually their lives at risk” Crawford cites examples of Internet pharmacies supplying drugs that were under strength, contaminated and mislabeled (Crawford 2004).

According to Won (2005) Drug-industry executives think the Internet and mail-order operations will be the biggest source of counterfeit drugs over the next five years, according to a report released today by Ernst & Young. According to James G Dickinson (2005):

The federal government in July shut down an alleged illegal Internet pharmacy for selling counterfeit drugs and issued a warning on other counterfeits found to have been sold in Mexican border pharmacies to individual patients from the U.S. The Internet pharmacy had sold more than $7 million in counterfeit Viagra and other prescription drugs over the past five years, according to the San Diego Union-Tribune. The San Diego-based operation required individuals to complete a $35 “doctor consultation” survey before receiving the prescriptions, but the survey was never shown to a health professional to evaluate whether a safety risk existed, the paper says (Dickson, 2005).

In a separate action, the FDA warned Americans about counterfeit versions of Merck’s cholesterol drug Zocor and generic Carisoprodol – used for treating musculoskeletal conditions – that had been imported from Mexico by individual Americans (FDA, 2005).

Over the last year patients suffering from pain, and other conditions that they are reluctant to see a doctor face-to-face, have had the option of consulting a doctor online. The ability to consult with a doctor online, and then to receive drugs as a result has come under much controversy. This has for the most part been as a result of not adequately screening patient’s records, or ordering from unregulated overseas pharmacies.

The Internet – a new way of marketing

Not all Internet pharmacies are illegitimate, however, and there are many pharmacies that provide the consumer with a legitimate prescription by overnight service. My last prescription came by mail. The whole transaction was completed over the Internet. It was a prescription that my doctor had given to me personally, however. As discussed, what constitutes a doctor patient relationship is at the crux of the online pharmacy debate. This of course has implications as to what constitutes a legitimate prescription. What constitutes a legitimate prescription is a hotly debated topic.

The Future

As noted, being able to consult a doctor over the phone, and then have one’s prescription filled by an Internet pharmacy is convenient for many people. As the American population ages, more and more people will have trouble getting to the doctors office, not to mention driving to the pharmacy. Clearly safeguards are needed if cyber-medicine is to raise the quality of medical care available to Americans. The online pharmaceutical industry has taken a number of steps to ensure that consumers are protected against unscrupulous online pharmacy operators including the certification of online pharmacies.

According to Henkel (2000) “One way consumers can ensure the quality of an online pharmacy is to look for the Verified Internet Pharmacy Practice Sites (VIPPS) seal.” According to Henkel (2000) any site bearing this seal has gone through a rigorous series of quality checks which are part of the Verified Internet Pharmacy Practice Sites program. Unfortunately as Henkel (2000) notes, “Because VIPPS certification is fairly new and voluntary, only a few sites have been certified so far.” Recognizing the problem of ‘rouge’ pharmacies, SquareTrade, has also implemented a program to protect consumers from ‘rouge’ pharmacies. According to SquareTrade, “The Licensed Pharmacy program verifies that your business is a pharmacy in good standing. Verified pharmacies can display the Licensed Pharmacy Seal on their websites – distinguishing themselves from unverified and rogue pharmacies.”

If these safe guards are not put in place, and legislation is enacted that makes it illegal to obtain a prescription from an online pharmacy based on an online consult, the black market for drugs will continue to thrive. Customs by its own admission only catches approximately 2% of all illicit prescription drugs that enter the US.

Negating the fact that through technology, one could enter into a doctor patient relationship that may be affordable. Security, as some have suggested could be accomplished through the use of video cameras and biometric scanners which would cut down on the number of fraudulent prescriptions written. Measures like these would put the convenience of using an online pharmacy out of the reach of those without the technology. One could also not prevent consumers from using off shore online pharmacies. While the FDA is presently trying very hard to get the Canadian government to enact legislation that would prohibit the export of drugs from Canada by mail it appears that the profit that results from the sale of drugs is causing the legislation to stall. As one Canadian pharmacy owner noted, however “We will just move to the UK.”

Ironically, the Canadian’s are offering to crack down, not because of any concerns relating to the sale of drugs online, but because Canada controls drug prices, making them far cheaper than the same drug in the US. The Canadian authorities are planning on cracking down “arguing that the system was created to help Canadians, not Americans.” The drug industry itself has gone so far as to black list Canadian pharmacies that sell to American customers over the Internet. With all the paranoia relating to terrorism there is a concern that any drug coming in from another country may be contaminated. There are no instances on record of a consumer having received a contaminated drug from Canada (Matthews, 2003).

Even more ironically with all the talk about the dangers of drugs purchased from overseas, some legitimate companies are now being forced to buy from other than US sources because they have been black listed by US drug manufactures (Matthews, 2003). Mathews (2003) goes on to illustrate this by pointing out that “Canadian suppliers, in particular, that have been blacklisted, are now turning to sources in Europe.” Mathews (2003) notes that while for the most part these European sources are legitimate and make a high quality drug. In some cases, however Mathews et al. (2003) note that the pharmacies are having to go ‘farther a field’ to find product.

Conclusion

While there need for controls to be put in place to regulate the practice of both medicine online and Internet pharmacies, we also need to acknowledge that science and technology has furthered the practice of medicine, and that the Internet will further it yet.

The Internet has the potential of expanding medical care to those that may not routinely seek it, or are too infirm to travel to the doctor’s office. While the present trend appears to be to make it illegal for a doctor to prescribe drugs without seeing the patient face-to-face there is also a move to establish rules and regulations that ensure that patients receive quality care over the Internet. Unfortunately medicine and politics have become so intertwined and doctors have inadvertently become unwilling agents in the war against drugs.

One can’t turn back the clock though, and according to Larkin (1999) “At a July 30 US Department of Commerce hearing on the benefits and risks of ‘drugstores on the net’, the question was examined.” The main issue was how to shutdown the online pharmacies run by unscrupulous individuals, while still fostering the legitimate online pharmacy business in order to both promote commerce and still protect the consumer (Larkin, 1999). According to Larkin (1999) “What’s new here is not the practice of pharmacy, but the way we communicate with and inform customers.”

At a January 26th 2004 FDCH Congressional Testimony Jeff Kimmell who is vice President and Chief Pharmacy Officer at drugstore.com, inc. commented, “There is little doubt that as consumers increasingly bear the burden of paying for prescription drugs, they will turn to the Internet for cost- effective alternatives.” As discussed, however, measures need to be taken to ensure that consumers don’t receive counterfeit, tainted or expired drugs. For more up-to-date information on doctors that practice telemedicine, pending legislation, and more visit: http://www.becomeone.com

Copyright (2005) http://www.becomeone.com

All rights reserved. No part of this article may be altered without the express permission of the author.

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Hooray for the Federal Rules of Evidence!

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The Federal Rules of Evidence used in the United States federal courts and adopted by many states and the military are codification of many years of common law evidence rules. The development of the modern rules of evidence has been a process of nothing more than putting old wine into new bottles. If one can understand common law notions of evidence the Federal Rules will be easy to understand.

The purpose of the Federal Rules of Evidence is to secure fairness in administration of trials; eliminate unjustifiable expense and delay; and to promote the growth and development of the law of evidence in order that truth may be ascertained and proceedings justly determined. As a former trial lawyer and current law school professor who teaches the rules of evidence to students, I view the Federal Rules of Evidence, adopted by Congress in 1975 as a master work of putting the old common law wine into a new bottle. I have used the Federal Rules of Evidence throughout my career.

This article is not about any specific common law rule or rules that may have been put into the new bottle known as the Federal Rule of Evidence. Instead, I write this to show how influential and widespread has been the use of the rules. Forty-four states, Guam, Puerto Rico, the Virgin Islands, and the military have all adopted all or parts of the Federal Rules for use in their court systems. This is a very good trend because the evidence rules of most states will be roughly the same throughout the United States.

The following paragraphs provide fundamental information about the jurisdictions that have adopted evidence rules patterned on the Federal Rules. They include information concerning the date on which the local rules became effective and when amended, if at all:

ALABAMA. Adopted by the Alabama Supreme Court effective January 1, 1996. No amendments.

ALASKA. Adopted by the Alaska Supreme Court effective August 1, 1979. Last amended October 15, 2003.

ARIZONA. Adopted by the Arizona Supreme Court effective September 1, 1977. Last amended June 1, 2004.

ARKANSAS. Adopted by the Arkansas Supreme Court effective October 13, 1986. Latest amendment on January 22, 1998.

COLORADO. Adopted by the Colorado Supreme Court Effective January 1, 1980. Latest amendment July 1, 2002.

CONNECTICUT. Adopted by the judges of the Connecticut Superior Court effective January 1, 2000. No amendments.

DELAWARE. Adopted by the Delaware Supreme Court effective February 1, 1980. Latest amendment December 10, 2001.

FLORIDA. The Florida Evidence Code was enacted by the Florida Legislature effective July 1, 1979. Latest amendment July 1, 2003.

GEORGIA. Governor Nathan Deal signed a House bill which made the Georgia rules effective January 1, 2013. No amendments.

GUAM. Adopted by the Guam Judicial Council effective November 16, 1979. Latest amendment July 18, 2003.

HAWAII. Enacted by the Hawaii Legislature effective January 1, 1981. No amendments.

IDAHO. Adopted by the Idaho Supreme Court effective July 1, 1985. No amendments.

ILLINOIS. Adopted by the Illinois Supreme Court effective January 1, 2011. No amendments.

INDIANA. Adopted by the Indiana Supreme Court effective January 1, 1994. Latest amendment January 1, 2004.

IOWA. Adopted by the Iowa Supreme Court effective July 1, 1983. Latest amendment February 15, 2002.

KENTUCKY. Enacted by the Kentucky Legislature effective July 1, 1992. Latest amendment July 1, 2003.

LOUISIANA. Enacted by the Louisiana Legislature effective January 1, 1989. Latest amendment August 15, 2003.

MAINE. Adopted by the Maine Supreme Judicial Court effective February 2, 1976. Latest amendment July 1, 2002.

MARYLAND. Adopted by the Maryland Court of Appeals effective July 1, 1994. Latest amendment January 1, 2004.

MICHIGAN. Adopted by the Michigan Supreme Court effective March 1, 1978. Latest amendment January 1, 2004.

MINNESOTA. Adopted by the Minnesota Supreme Court effective April 1, 1977. Latest amendment January 1, 1990.

MISSISSIPPI. Adopted by the Mississippi Supreme Court effective January 1, 1986. Latest amendment May 27, 2004.

MONTANA. Adopted by the Montana Supreme Court effective July 1, 1977. Latest amendment October 18, 1990.

NEBRASKA. Enacted by the Nebraska Legislature effective December 31, 1975. Latest amendment July 13, 2000.

NEVADA. Enacted by the Nevada Legislature effective July 1, 2004. No amendments.

NEW HAMPSHIRE. Adopted by the New Hampshire Supreme Court effective July 1, 1985. Latest amendment January 1, 2003.

NEW JERSEY. Adopted by the New Jersey Supreme Court and the New Jersey Legislature through a joint procedure effective July 1, 1993. Latest amendment July 1, 1993.

NEW MEXICO. Adopted by the New Mexico Supreme Court effective July 1, 1973. The latest amendment became effective February 1, 2003.

NORTH CAROLINA. Enacted by the North Carolina Legislature effective July 1, 1984. Latest amendment October 1, 2003.

NORTH DAKOTA. Adopted by the North Dakota Supreme Court effective February 15, 1977. Latest amendment March 1, 2001.

OHIO. Adopted by the Ohio Supreme Court effective July 1, 1980. Latest amendment July 1, 2003.

OKLAHOMA. Enacted by the Oklahoma Legislature effective October 1, 1978. Latest amendment November 1, 2003.

OREGON. Enacted by the Oregon Legislature effective January 1, 1982. Latest amendment July 3, 2003.

PENNSYLVANIA. Adopted by the Pennsylvania Supreme Court effective October 1, 1998. Latest amendment January 1, 2002.

PUERTO RICO. Enacted by the Puerto Rico Legislature effective October 1, 1979. Latest amendment August 30, 1999.

RHODE ISLAND. Adopted by the Rhode Island Supreme Court effective October 1, 1987. No amendments.

SOUTH CAROLINA. Enacted by the South Carolina Legislature effective September 3, 1995. No amendments.

SOUTH DAKOTA. Enacted by the South Dakota Legislature effective July 1, 1978. No amendments.

TENNESSEE. Adopted by the Tennessee Supreme Court effective January 1, 1990. Latest amendment July 1, 2003.

TEXAS. Adopted by the Texas Supreme Court effective March 1, 1998. No amendments.

UTAH. Adopted by the Utah Supreme Court effective September 1, 1983. Latest amendment November 1, 2004.

VERMONT. Adopted by the Vermont Supreme Court effective April 1, 1983. Latest amendment May 27, 2003.

WASHINGTON. Adopted by the Washington Supreme Court effective April 2, 1979. Latest amendment September 1, 2003.

WEST VIRGINIA. Adopted by the West Virginia Supreme Court effective February 1, 1985. Latest amendment January 1, 1995.

WISCONSIN. Adopted by the Wisconsin Supreme Court effective January 1, 1974. Latest amendment March 30, 2004.

WYOMING. Adopted by the Wyoming Supreme Court effective January 1, 1978. Latest amendment February 28, 1995.

THE MILITARY. The Military Rules of Evidence were adopted by Executive order No. 12,198 March 12, 1980. Latest amendment by Executive Order No. 13,262 April 11, 2002.

THE COMMONWEALTH OF THE NORTHERN MARIANA ISLANDS. No date of adoption found.

THE U.S. VIRGIN ISLANDS. No date of adoption found.

What an impressive list of adoptions and enactments patterned after the Federal Rules of Evidence! Several jurisdictions have not adopted rules of evidence based on the Federal Rules of Evidence. They are: California, the District of Columbia, Kansas, Massachusetts, Missouri, New York and Virginia.

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Plasma Donations Put a Price on Human Life

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Reminiscent of a medical facility, this plasma center, built only a year before is brimming with white lab coats, face shields and medical gloves. The sound of Velcro and beeps from blood pressure machines and the whirring of hematostats as they separate blood and plasma fill the air.

The appearance is all so sterile and clinical, but the workers here are not medically certified, they are only required to have a high school diploma and all are trained by each other. Of the almost 70 workers in this building, besides the LPN nurses and the one RN, certified phlebotomists (medically trained personnel that collect blood, plasma and tissue samples from patients) are 10 % of the workforce here which is a crapshoot for professionalism in the taking of blood and plasma.

As the donors (people who give a voluntary gift of plasma) are processed through, their vitals are taken and their appearance assessed as per the companies standard operating procedures (SOP). 38% of those interviewed come because they need the money to help pay for food, rent or bills, 60 % donate because the money supplemented their vacations or spending money, the other 2 % came because they believed that they were “Saving Lives.” Most are not your typical college students, but instead housewives, part-time workers or the working poor.

Plasmapherisis (the removal, treatment, and return of blood plasma from blood circulation) began back in the 1940’s in order to harvest clotting agents by the pharmaceutical companies – now there are more than 500 donation centers in the United States and more being built every day.

The buying and selling of Blood and Plasma is a multi-billion dollar per year business. Plasma is more commercial than Blood and can not be synthetically replicated. In 1988, more than 21 years ago, the industry made over 2 billion dollars per year alone making the current numbers staggering, but incredibly secret.

US Federal regulation is more liberal than anywhere else in the world allowing up to 60 liters (127 pints) a year. The next highest producing country is Canada allowing only 15 liters per year, which is the recommendation from the World Health Organization. More than half of the plasma used in medicines worldwide is from the US.

While US donors are the source of 60% of the world’s plasma, foreign companies like huge mosquitoes, are the ones that control the product from Japan, West Germany, Austria and Canada, flying in to the US to puncture the blood and plasma supply and then fly the profits home to feed on them. Not only do foreign companies own the majority of plasma collection centers, the majority of plasma medications are also sold abroad as well.

There are two different types of plasma donations…the first is non-profit. The largest would be The American Red Cross. According to FDA regulations, truly donated plasma and blood, without any funds exchanging hands between the donor and the organization, is the only blood or plasma that can be transfused into humans. If an individual is paid any money at all, for their time or for their plasma, it can not be used to “Save Lives” per se. Because for-profit donation centers feed on the need or the greed of the economic world temperature, non-profit donation centers are suffering. When non-profit donation centers suffer, then those who need plasma: burn, shock or trauma victims go without. Those looking to make a humanitarian donations should be donating blood and plasma at non-profit donation centers like the American Red Cross.

Donations that are “paid” for are sold to drug and research companies and with the economic downturn of 2007-2009, plasma donation centers are on the rise with one of the largest Austrian Pharmaceutical backed donation centers achieving a 19% rise in stock prices within a quarter while other markets were plummeting.

The ethical question of Plasma Donation comes at a cost. Organ donation is not an unusual thing, but bodily “donation” that is suppose to help and not hinder human survival is questionable when big business gets involved, and for-profit donation of blood and plasma is very big business.

Plasma that is donated to drug and research companies is refined down and made into medicines that “Save Lives”. What is the cost of those medicines to those that would die without them? $50,000.00 to $80,000.00 per year, which can really change the slogan, “We Save Lives” to “We Cant Afford to Live”. Those without insurance or government funded backing can not afford the medications or treatments and without those “donated” treatments, die. Most are government funded solutions, which means tax payers, donors or non-donors, are paying to treat those that would die without the treatments that are suppose to be a voluntary gift…so the saying, “Give until it hurts” may be more applicable.

For-profit donation centers started targeting college students in the 1970’s to improve the quality of the plasma supply. Companies speculated that college students should be healthier than the average population. In 1999 a study was conducted by Ohio University which found that university plasma donors were not as healthy as once thought. Paid donors are three times more likely than non-donors and four times more likely then Red Cross donors to drink alcohol five or more times a week. One eighth of non-donors, one quarter of Red Cross Donors to one third of paid donors smoke tobacco. Consumption of toxins or unhealthy lifestyle is not the only issue at hand today, body piercings, tattoos and branding are other issues that pose unhealthy donation bases as well. Body art is not always visible and unless confessed to, can not always be subject to scrutiny by the donation center.

For profit donation centers will pay $8.00 -$20.00 dollars for the first donation and then to encourage the donor to come back, will pay a higher price for the second donation within the seven day period.

Depending on the weight of the individual, the donation center will take 690mL to 880mL per donation. The 880mL bottles bring a price of anywhere from $300.00 to $1,700.00 when sold to the Pharmaceutical companies. If there is anything wrong with the plasma, if it’s hemolysised (infused with red blood cells) or if the plasma is lipemic (excess fat within the plasma) the plasma is sold to veterinarian companies and bring a lesser price for the donation center.

Plasma donation was worth approximately 4.5 billion dollars in 2007. Today there are approximately 1.5 to 2 million donors worldwide and is expected to grow significantly in the struggling economy of 2009.

Because of the rapid growth within the industry, corporations train their workforce to take the donations, paying an average of $10.00 per hour. The workforce usually does not have medical certification or medical training unless they are one of the 8 LPN’s or RN’s that are hired. A licensed medical doctor covers the center with his license, but he is rarely seen on the floor of the center. He comes in maybe once a week to sign charts and watch vitals being taken once on those being trained and then he is off again, taking only his cut of the centers profits. The corporate training is not done by the LPN’s or RN or even by the doctor, it is done by regular employees that do not have medical certification or license.

Corporate training consists of reading of Standard Operating Procedures in a conference room for several hours, sometimes days, then you are put out on the floor with a trainer to watch him/her go through the motions. If you have an efficient trainer, then you can process with professionalism, but if you do not, then most Medical Historians (Someone who takes vitals, transcribed medical information and does basic phlebotomy) struggle and their bedside manner, technique and record keeping will leave much to be desired and the donors do not get the care that they may need.

In this center, processing time is a task master. This center processed 570 donors in one day with an average of 390 customers a day. From the time donors check in with the receptionist until they scan out they are timed. Time is money in this industry. When doing vitals, the Medical Historians are given a maximum of 1 minute 21 seconds to complete the processing of the donor and sending them out to the phlebotomy floor for the donation which is not much time to practice accuracy. There is no time to check your gloves for contamination issues such as plasma, mucus or blood, so donors are subject to cross-contamination every time they come into the center. Company policy states that gloves should only be changed when they are contaminated with blood, torn, cut or every two and one-half hours.

That is to save time between donors and the crack of the whip comes from the managers as they wait with stop-watches and pink slips over their white coated slave labor force. The Medical Historians are moving so fast in order to keep from getting fired that there were 2 contaminations of workers within 2 months…both from filled but broken capillary tubes that were shoved into the workers skin through their gloves or through their lab coats and scrubs and into their skin. One contamination happened when a Medical Historian tried to pull a hair out of her mouth and realized that she had just consumed the previous donors blood. Donors have to ask specifically to have the Medical Historians “change your gloves” before they are allowed to do it.

Phlebotomists on the floor are moving just as fast. They have one minute to clean, find the vein and stick the donor. They can stick 3 times, twice per arm unless there is a loss of red blood cells or the donor is in danger and needing saline, then they can stick the third time for emergencies. This causes the likelihood of Hematomas (Blood that collects under the skin or in an organ) for the donors, large bruises over 3 inches and tender areas on the arm. Sometimes, because a donor has to be stuck twice, both arms result in hematomas. Donors have to heal up for several weeks before they can return to donate, which makes the donation process an unreliable source of income for anyone.

When this center is running at full gear, processing 570 donors per day, most who work an 8 hour shift are not allowed to take lunches and sometimes not allow to take bathroom breaks. The pace is fast and furious and as soon as the donors are processed and the plasma is back in the lab, they tear down the used sets and get ready for the next donor. Used sets can be dangerous, they are suppose to be heat sealed but sometimes if there is equipment failure, the tubing doesn’t get sealed completely and when the phlebotomist pulls the tubes off the machines, plasma can splash up and out into the face, unprotected arms and saturate clothing. The Personal Protective Equipment required by OSHA doesn’t always cover everything it needs to cover, especially since Personal Protective Equipment is not fitted or trained on, so the workers are in constant hazard of contamination, which happened at least once within a 3 month period of time in this center. There are not only hazards to the Employees, but to the donors as well in this atmosphere. Because the center is trying to fill beds as soon as possible, sometimes beds are not cleaned before the donors sit down and donors can find themselves sitting in the blood of the last donor.

There are 22 Right-to-Work states in the US, which means that in order to receive lunch and bathroom breaks, they have to be contractual or within Union Guidelines, if they are not, the Department of Labor can not enforce bathroom breaks or Lunches for the workers. Of the 22 Right-to-Work states, plasma centers flood at least 13 of those states, and build fewer plasma centers in non-right to work states.

Employees have a hard 8 to 10 hour shift in front of them, not only working long hours without breaks, but working in a precise and fast paced environment as well and without the certified medical training that is desired.

Because they do not have the training and because the bottom line pushes ethics, sometimes shortcuts are taken. When the plasma is delivered to the lab, the lab tech has only 30 minutes to process all those bottles. If the bottle is leaking, that bottle has to be thrown out because it is air contaminated, if the bottles take longer then 30 minutes to process before being put in the storage freezer, they are thrown out, a loss of a lot of money. What has happened in the past is that the lab tech will push the bottles back over into more time to process, or the lab tech will process an air contaminated bottle and just wipe it down, or instead of taking samples from each of the plasma bottles as required by FDA, they will open one bottle and take all the samples from that one bottle…because it saves time. These infractions can close a center, but only if it is caught and reported to the FDA, which questions the purity and usability of the plasma in the system and poses the question of contamination of medications as well.

Workers who stay in this business have after 3 months suffer from foot problems, back problems, hip problems, headaches, varicose veins and neck problems that are not covered by Workman’s Comp and the conditions are not covered by OSHA. This doesn’t include the possibility of contamination that may render them with HIV, Hepatitis or other communicable diseases. These are long lasting ailments and conditions with long lasting effects. Although there are only a few that stay in this field longer than 6 months, Supervisory positions are no better.

Supervisors have demanding jobs as well. They oversee the operations to maintain not only FDA standards but also the Company’s SOP (Standard Operating Procedures). Supervisors not only man the course of Medical Historians, but also phlebotomists on the floor and incoming data entry. A supervisor must be trained and tested on all aspects of phlebotomy and medical history as well as incoming data. If the Medical Historians and Phlebotomy work 8 to 10 hour shifts without lunch or bathroom breaks, then the supervisor works 12 hour shifts with the same conditions and with the added responsibility of catching all non-conforming events that may give the center a Quality Incident Report that, depending on the severity, may be reported to the FDA if it effects the health of the public.

When new donors come through the door, they are required to read a “New Donor” booklet, which has in it all the side effects, what to expect and some of the documentation that they will be required to sign. From the time they check in until they are done reading the book, even the donors are timed, up to 10 minutes to read their packet of legal documents. After they are done reading, they are asked for two forms of identification, usually a current driver’s license and social security card will be sufficient. If the driver’s license is not current or an address is not current, then a piece of mail that is dated less than 60 days can be used to verify the address. Social Security must be verified by Social Security Card, current Tax Information or Pay stub.

Plasma donors are usually not aware of side effects and most likely told that plasma donations are safe in the long term…the reality is that 7% of the human population has an anaphylactic reaction to sodium citrate or saline of which they will need intravenous medications immediately. If they do not receive treatment within minutes, the reaction is fatal.

In this center, we have at least 5 to 6 lesser reactions a day, sometimes more. Immediate side effects can be fainting, bleeding, edema at the venipuncture site, nausea, vomiting, drop in blood pressure, faintness, dizziness, blurred vision, coldness, sweating or abdominal cramps.

If allowed to progress the side effects can be tingling around the mouth or in the limbs, muscle cramps, metallic taste in the mouth and further reactions can lead to irregular heartbeat or seizures.

After prolonged donations, 12% of donors will have a lowered level of antibodies, causing an inadequate immune system response and the probability of increased infection or disease for the rest of their lives.

Plasma donations can save lives, especially when given freely and as a humanitarian gesture…drug and research companies would like the public to believe that they are the good guys in order to increase the bottom line in this Multi-billion dollar business, profiting on the generosity of some and the desperation and greed of others, treating donors like Cash Cows grazing on the bottom line.

For-profit donations feed a fire-storm of ethical questions such as, “if selling human organs is immoral, unethical and illegal, then what makes selling Plasma any different?” “If harvesting a human organ and holding it ransom to those that can pay the price to live, if selling it to the highest bidder is wrong, then isn’t harvesting plasma and selling it to those that would die without it the same thing?” What is the cost of a human life? With 15 million donations a year, the plasma industry looks the donor gift horse in the mouth everyday and laughs all the way to the bank. For-Profit plasma companies have a win-win situation…donors give their plasma or practically give their plasma to the industry and the blood sucking, plasma hoarding corporations can turn around and charge $50,000.00 to $80,000.00 a year to allow a person to live, long term cost projections are at $3.7 million to $5.9 million for medications that allow one person to live a normal life…and now we can put a price on what a human life is worth to the plasma industry.

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How to Pick the Right Auto Body Repair Shops

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Some of the biggest questions people run into deal with the repairing their vehicles. Many times people are confused and don’t know how to go about picking the right auto body shop. What process should I run through in picking the right vehicle repair shop? What questions should I consider?

What value am I getting for my Auto Body Repair?

The most important question in determining what auto body repair shops is: What value am I getting in repairing my vehicle here? Many body shops out there are looking for unsuspecting customers and ways to pad their bottom dollar. A lot of times body shops will offer the lowest price because they know this will attract customers. Unfortunately, from a customer standpoint choosing the lowest price is not always the way to go.

Daniel T., Vice President of National Auto Parts, in Dallas, Texas, concurs that doing this will only create more car issues in the future. “Repairing your vehicle is always about what you get in return. These days, body shops continue to push the limits of their customers to see how much more they can get away with. At this point the body shop knows exactly what they’re doing. Is the customer to know the better?”

What can I do to protect myself?

A solution that’s been picking up a lot of traction recently is hiring a third party to assist you in this area. There are a few good car crash consultants out there that will help you figure out what’s being put on your vehicle and how the vehicle’s being repaired. When looking for a good car crash consultant selecting one that gives you a lot of insight on the repair and product being used is imperative. Using these specialists provides visibility in an area with many questions.

Another way is looking for a detailed report of the work being put into the vehicle and reviewing the warranty the shops offers. When you get into an accident, every insurance gives you an assessment of the damages, take a look at the sheets and read over to see what product they’ve listed for use. Auto Body Shops sporadically will attempt to use cheaper parts to make more money. Requesting the use of what’s listed on your insurance assessment is not unusual and will help protect against this. In regards to warranties, most legitimate body shops will have an extensive warranty and stand by their work.

Where should I look for the body shop?

Driving to the nice plush auto body repair shops off the highway might be convenient, but doing this often drives up the price of the job. “All businesses have costs and are in it to make money. With this assumption, you have to believe any cost a business incurs will be passed onto their consumer,” Daniel says. Hanging off the highway, and looking more in-city gives any prospective client a better chance to keep labor costs low. Prices per hour for labor can vary wildly from $30-$100 for the same type of work. Don’t misunderstand the shop may not look the best, but you can be guaranteed going this route will provide good value.

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