Seven-year-old Gabriel Meyers didn't want soup for lunch one Thursday in April, 2009. When his 23-year-old foster brother sent Gabriel to his room for dumping his soup in the trash, Gabriel threatened to kill himself. He kicked his toys around his room, then locked himself in the bathroom.
Police reports say Gabriel was home sick that day from his elementary school in Margate, Florida, under the care of Miguel Gould, his foster father's son. Around 1 p.m., city police responded to Gould's frantic 911 call and found Gabriel had hanged himself.
A troubled child who had previously suffered from neglect, sexual assault and abusive parenting, Gabriel spent the previous year shuttling among several foster parents while taking a constellation of anti-psychotic medicines, including Lexapro and Vyvanse, to control his depression and attention deficit hyperactivity disorder. Like most children in Florida foster care, Medicaid paid Gabriel's medical expenses.
Just one month before his suicide, Gabriel's doctor prescribed him Symbyax, an anti-depressant restricted for treatment of children. The medication's FDA-required label features a warning that use of the drug by children or teenagers can lead to suicide.
Symbyax does not meet criteria established by Congress for Medicaid reimbursement, so it is illegal for Medicaid to pay for a prescription of the drug to a child. Sohail Punjwani, the doctor who prescribed Symbyax for Gabriel, received a stern letter from the FDA about his history of over-prescribing mental health drugs.
According to a number of foster care experts who spoke with Politics Daily, children in foster care, who are typically concurrently enrolled in Medicaid, are three or four more times as likely to be on psychotropic medications than other children on Medicaid. Alarmingly, many of these drugs are medically prohibited for minors and dangerous to the children taking them. Often young patients under state supervision are also prescribed three or four high-risk drugs at a time -- all paid for by Medicaid.
State foster care programs and child protective services have had mixed success addressing the pervasiveness of dosing their clients with prescription psychotropic drugs. Using federal Medicaid money to purchase dangerous prohibited prescriptions for children, which cost the government up to $600 per dose, is technically a violation of the law.
Now, the Senate Subcommittee on Federal Financial Management, chaired by Sen. Tom Carper (D-Del.), has asked the Government Accountability Office to look into the drugging of foster care children. The investigators will attempt to account for estimates in the hundreds of millions of dollars of possible fraud arising from prescriptions for drugs explicitly barred from Medicaid coverage. The GAO is collecting data from Oregon, Massachusetts, Florida, Maryland, Minnesota and Texas, to search for patterns of abuse. This effort marks the first time suspicion of Medicaid fraud related to psychotropic drugs has been examined at the federal level. According to Senate staffers working on the investigation, the committee will likely hold hearings on the matter later this year.
Psychotropic medications act on the central nervous system and alter brain function, mood and consciousness. The GAO investigation is chiefly focused on anti-depressants, widely used in foster care in dangerous combinations, and for so-called "off-label" uses to treat symptoms for which they have not been medically approved. Anti-psychotic medications have been a factor in a number of children's deaths.
Statistics on psychotropic drugs in foster care have until now come out in scattered reports, mostly from investigations of foster care failures by individual states. For example, in 2003 a Florida Statewide Advocacy Council study found that 55 percent of Florida's foster children were being administered psychotropic medications. Forty percent of them had no record of a psychiatric evaluation. Another Florida report also indicated anti-psychotic medication use increased an astonishing 528 percent from 2000 to 2005.
A Texas state study in 2004 revealed that 34.7 percent of Texas foster children were prescribed at least one anti-psychotic drug -- and 174 children aged 6-12 in the care of the state were taking five or more psychotropic medications at once.
Last April, an investigation by the Atlanta Journal-Constitution exposed several companies operating foster care homes in Georgia repeatedly used anti-psychotic medications to "subdue" children in their care. Despite being cited repeatedly, none of the agencies were fined more than $500.
According to child care experts and assessments by both advocacy groups and state government agencies, many states lack efficient records management and adequate oversight of foster care, contributing to a pervasive lack of medical continuity for the children. Social workers have oversized caseloads of foster children, who are often shunted between families and prescribed anti-psychotics from doctors unfamiliar with their medical histories. Without a case history, experts and foster care alumni say, doctors are more likely to add medications than take them away, resulting in record numbers of children dispensed several anti-psychotic medications at once. In many cases, the drugs are prescribed off-label to youngsters with behavior problems.
Julie Zito is a professor of pharmacology at the University of Maryland who conducted a 2008 study of the texas foster care system that found 41 percent of the children prescribed psychotropic drugs received three or more different medications. She told Politics Daily what little research has been done suggests children in foster families are rarely assessed properly, a failure leading to serious effects. There has been no research on multiple-drug regimens, Professor Zito explained, and "blitzes" of medication have become a pervasive way of dealing with behavior problems in foster care. "We've expanded the medication practice in response to children not getting better," she said, and children who fail to improve, "are getting more medication."
Pharmaceutical companies manufacturing psychotropic drugs have played a major role in encouraging their increased use on foster care clients. Drug companies participate in aggressive marketing, conduct misleading research about efficacy and safety, and in some cases, "bribe" psychiatrists to prescribe their drugs, according to Zito and Jim Gottstein, an Alaska lawyer and founder of the Law Project for Psychiatric Rights, who has mounted several lawsuits against pharmaceutical corporations.
For example, last year the St. Petersburg Times reported that a psychiatrist in Jacksonville, Florida, was paid for speaking engagements to encourage her to prescribe Seroquel, a drug used to treat bipolar disorder and schizophrenia, and a neurologist in Tampa received free trips to Spain and Scotland from AstraZeneca, the drug's British manufacturer, for her innumerable prescriptions of the drug for headaches. Seroquel is the top-selling anti-psychotic drug in the United States, with more than $4 billion per year in worldwide sales. AstraZeneca recently paid $520 million to settle lawsuits -- some brought by doctors who had been offered swag in exchange for prescriptions -- over its illegal promotion of off-label uses for Seroquel.
According to Jim Gottstein, the increase of anti-psychotic use in foster care amounts to "drug companies sacrificing children's lives on the altar of corporate profits." Gottstein recently filed a citizen's suit on behalf of the state of Alaska against several doctors, drug companies and insurance companies, claiming that they knowingly promoted Medicaid fraud.
Reform Attempts
In response to the devastating study of the Texas system in 2004, that state's top health agency introduced a new set of guidelines stressing specific treatment goals for medication and "informed consent" of parents and guardians. That effort led to decreased use of psychotropic drugs relative to the number of children enrolled in foster care from 2002 to 2009, according to data from the Texas Health and Human Services Commission.
In May 2005, Florida expanded foster parents' rights to reject psychotropic treatment for the children in their care. Four years later, however, a review found that the new requirements were being flauted, and the panel that investigated Gabriel Meyer's suicide concluded that every level of the Florida system had missed "warning signs" that Gabriel's care was inadequate. Thirteen percent of Florida foster children were on one or more psychotropic drug, and 16 percent of those were not approved by parents or guardians.
In 2008, Rep. Jim McDermott (D-Wash.), the only psychiatrist in Congress, introduced a bill titled Invest in KIDS Act, which included stronger oversight for prescription medications in foster care. McDermott held a hearing on the use of psychotropic drugs in foster care, but the bill died in committee. Near the end of George W. Bush's second term, Congress passed a law, co-sponsored by McDermott, that included increased oversight for "mental health" in foster care, but did not specifically mention psychotropic drugs.
"Some children in foster care may need and benefit from psychotropic medication," McDermott told Politics Daily. "But these drugs should not be used as a shortcut to treat foster children when more effective treatments, including counseling, might provide long-term benefits."
Federal and state agencies have pursued drug companies that illegally market their drugs for off-label uses, a practice that experts say heavily contributes to the overuse of psychotropic drugs in foster care.
Last year, a Justice Department action against Pfizer led to a $2.3 billion settlement, the largest in the department's history. Companies convicted of major health fraud are barred from participating in Medicaid and Medicare. But worrying that a conviction would cause Pfizer to fail and cost its employees their jobs, the government allowed Pfizer's shell company, which exists solely to plead guilty in lawsuits, to be charged instead, and the drug company paid a fine. Pfizer maintains that it did not break the law.
In 2006, The New York Times obtaine a batch of internal documents that showed Eli Lilly, the maker of Zyprexa, a medication approved exclusively for treating the severe mental illnesses of schizophrenia and bi-polar disorder, was suppressing information on the drug's harmful side effects and advertising it illegally. Lilly paid $62 million to settle lawsuits with 32 states and the District of Columbia, and agreed to ensure that its marketing complied with the law.
How to Fix It
The problems that lead to drug abuse in foster care are complex and deeply entrenched, but activists and advocates have proposed a number of solutions for limiting the overuse of anti-psychotics. Foster care experts, including a current task force of the American Academy of Pediatrics, believe that getting foster children a "medical home" -- one physician who manages their care over the long term and has access to relevant records -- would reduce the overprescription of psychotropic medications.
"Having a drug to take the edge off the pain and fear and sadness saved my life a time or two, but it's not a lifestyle." said Misty Stenslie, a former foster child who is currently the deputy director of Foster Care Alumni of America. Children under the protection of government agencies deserve the assurance of safe and decent health care. Especially, as Stenslie points out, "We can't give kids what they really need, and that's a family and love."
For years, Internet advocates have warned of the doomsday scenario that will play out on Monday: Google and Verizon will announce a deal that the New York Times reports "could allow Verizon to speed some online content to Internet users more quickly if the content's creators are willing to pay for the privilege."
The deal marks the beginning of the end of the Internet as you know it. Since its beginnings, the Net was a level playing field that allowed all content to move at the same speed, whether it's ABC News or your uncle's video blog. That's all about to change, and the result couldn't be more bleak for the future of the Internet, for television, radio and independent voices.
How did this happen? We have a Federal Communications Commission that has been denied authority by the courts to police the activities of Internet service providers like Verizon and Comcast. All because of a bad decision by the Bush-era FCC. We have a pro-industry FCC Chairman who is terrified of making a decision, conducting back room dealmaking, and willing to sit on his hands rather than reassert his agency's authority. We have a president who promised to "take a back seat to no one on Net Neutrality" yet remains silent. We have a congress that is nearly completely captured by industry. Yes, more than half of the US congress will do pretty much whatever the phone and cable companies ask them to. Add the clout of Google, and you have near-complete control of Capitol Hill.
A non-neutral Internet means that companies like AT&T, Comcast, Verizon and Google can turn the Net into cable TV and pick winners and losers online. A problem just for Internet geeks? You wish. All video, radio, phone and other services will soon be delivered through an Internet connection. Ending Net Neutrality would end the revolutionary potential that any website can act as a television or radio network. It would spell the end of our opportunity to wrest access and distribution of media content away from the handful of massive media corporations that currently control the television and radio dial.
So the Google-Verizon deal can be summed up as this: "FCC, you have no authority over us and you're not going to do anything about it. Congress, we own you, and we'll get whatever legislation we want. And American people, you can't stop us.
This Google-Verizon deal, this industry-captured FCC, and the way this is playing out is akin to the largest banks and the largest hedge funds writing the regulatory policy on derivative trading without any oversight or input from the public, and having it rubber stamped by the SEC. It's like BP and Halliburton ironing out the rules for offshore oil drilling with no public input, and having MMS sign off.
Fortunately, while they are outnumbered, there are several powerful Net Neutrality champions on Capitol Hill, like Nancy Pelosi, Harry Reid, Henry Waxman, Jay Rockefeller, Ed Markey, Jay Inslee and many others. But they will not be able to turn this tide unless they have massive, visible support from every American who uses the Internet --- whether it's for news, email, shopping, Facebook, Twitter --- whatever. So stop what you're doing and tell them you're not letting the Internet go the way of Big Oil and Big Banks . The future of the Internet, and your access to information depends on it.
Iran is one of the world's most significant nations in terms of history, culture and intellectual capacity, and is matched in the Middle East perhaps only by Israel.
It is a small wonder, then, that when Iran's hard-line and irascible president talks of building military capability and destroying Israel, Tel Aviv feels its survival is menaced and that Tehran's regime is its nemesis.
For all of its 61 years in existence, Israel has considered itself in a permanent war of survival. It has developed a national system which places great emphasis on its military and intelligence capabilities.
Starting from scratch, Israel has developed technologies which are truly world-leading, especially in the delivery of shock and awe on any potential enemy.
For the early part of its statehood, Israel had shared the support of the United States, as its protector and military hardware supplier, with the Shah's Iran.
When a belligerent Saddam Hussein took power in Iraq, both the Shah and Israel were uneasy and often co-operated in exploiting technology, both US and home-grown in Israel.
There is documented evidence that Israel supplied Iran with communications equipment and the supporting paraphernalia needed to allow both countries (and probably the US Central Intelligence Agency) to eavesdrop on Iraq.
The great divide
The Iranian Revolution changed all that and since 1980, Israel and Iran have grown apart. So far apart, in fact, that there is a real risk of armed conflict between the two states.
What makes the world sit up and take note is that Israel is a nuclear power with delivery systems which can reach Iran – and Iran is, according to US experts, just two years away from creating a nuclear strike capability of its own.
US experts believe Iran will be able to produce nuclear weapons material in the next few months.
For Jordan, Iraq and Saudi Arabia – and even the Gulf states - this is particularly worrying as any nuclear-tipped missiles would fly overhead no matter who launches them.
In addition, Israel has a sophisticated - and tested - anti-missile system called Arrow, which could knock out a potential Iranian first strike. The problem for Israel's neighbours is not the technology but where the debris might fall if the Arrow were ever to be used.
Israel has watched with growing horror as the rhetoric from Mahmoud Ahmadinejad, the Iranian president, stokes tensions and as Tehran appears to be determined to create a full nuclear weapon capability.
Israel has taken steps to improve its nation's defences and its long-range strike capability. There is no doubt that the Israeli military could mount a successful air strike against targets in Iran and certainly that the Jericho series of ballistic missiles could hit targets with great accuracy.
Unwanted scenarios
But it is also clear that any such first strike would provoke clear and rapid hostile reactions around the world, especially from moderate Arab nations with whom Israel seeks accord and co-operation against Iran, as well as by the European Union and others opposed to first strike operations – in favour of a self-defence option.
The Middle East peace process would be indirectly destroyed and Iran's proxies in Lebanon and Gaza would probably enter the fray against Israel.
Israeli interests worldwide could also be threatened.
Iran is not yet in a position to launch a first strike against Israel. This is perhaps a key concern because Israel has a reputation for not allowing a first strike capability to develop.
It has a record of destroying the Egyptian ballistic missile industry under Gamal Abdel Nasser, the late Egyptian president; destroying French-built Iraqi nuclear reactors outside Baghdad at Osirak in 1981, and interdicting the supply of arms moving through Sudan as recently as January this year.
Nevertheless, Iran has had a series of short-range ballistic missiles for three decades, having developed them for the 'War of the Cities' during the war with Iraq. Much of the technology was originally bought from Pakistan and later North Korea.
There is Russian and Chinese technology extant as well – even technology bought commercially in electronics supermarkets in Japan as a report in Jane's Defence Weekly revealed 15 years ago.
But creating a weapon in sufficient numbers and capability to destroy key targets in Israel is a different matter.
Even if Iran had a nuclear device now, it would take some time to 'weaponise' it to create a first strike capability. North Korea is struggling with same problems which leads many to believe there is a union of need between the two otherwise unlikely bedfellows.
Black market technologies
Iran's defence industries have created good technologies of their own since the US-inspired arms embargo which followed the cessation of hostilities with Iraq in 1988. Battlefield weapon systems were developed from black market Russian missiles and by some clever adaptations of US technology.
For example, Iran's military took medium-range air-to-air missiles (originally exported to Iran in the time of the Shah for the F-14 Tomcat and F-4 Phantom fleets) and reconfigured the guidance systems from air-to-air to air-to-ground.
Israel has also seen Iran, under Ahmadinejad, support both Hezbollah and Hamas. Recent military operations in South Lebanon in 2006 and against Hamas in Gaza in 2009 have witnessed a haul of Iranian-supplied systems.
Israel has put extreme diplomatic pressure on Russia about the extent of weapons sales to Iran. The unlikely alliance between Iran and Syria has also contributed to Israel's unease and feeling that it is - like in the early 1960s - surrounded by potential aggressors.
Washington's anti-Iran stance under George Bush, the former US president, led to speculation that the US would provide the technology for Israel to launch a conventional bombing raid – or rather series of raids – against Iranian nuclear facilities in known locations near Shiraz and Isfahan.
What to bomb?
The problem for Israel in mounting such operations would not be the technology of reaching the target areas, nor destroying those seen, or even the opposition of neighbours, but actually detecting the right facilities.
Iran, using North Korean advisers, has managed to bury and hide its main facilities. This makes a first strike difficult in military terms while the risk of collateral damage makes it impossible in political terms.
Israel has been trying a charm offensive with some moderate Arab states. It has highlighted that the physical and political fallout stemming from Ahmadinejad's more aggressive posture would be damaging for all.
Israel's case has not been helped by Operation Cast Lead, the name it gave its offensive against Hamas in Gaza last January.
Ahmadinejad's inauguration for a second term after the disputed elections is another factor. Traditionally, leaders under pressure in hard-line states have used military adventures to divert public opinion.
One only has to remember the actions of the Argentine Junta in 1982 when it invaded the Falkland Islands or actions in Northeast Africa over several decades.
Military and intelligence organisations look at a nation's potential threat by examining key attributes.
These are 'military capability' – could a nation actually carry out a military strike; "political will" – does a nation actually want to expend that much treasure and 'blood'; "an understanding of the consequence" – does the nation's leadership understand where the ripple caused by its casting of a stone into the pool of peace would stop?
Hard-line versus unpredictable
Taking each nation in turn – Israel has the military capability of a nuclear or non-nuclear strike against Iran and hence the war experience of 1967, 1973 and 1982 to fall back upon.
The current government in Tel Aviv is hard-line enough to both take the action and to ride out the political storm.
But it is also pragmatic and - despite its inability to understand the West's clear opposition to its housing policies in Jerusalem and the West Bank - guarded in its use of military force on a regional scale.
US posture is also a determining factor in any decision to strike. The fate of three US tourists apparently being held by Iran could further bolster the position of US hawks on Iran in the Obama administration.
Iran, on the other hand, is completely unpredictable, especially given the competing power structures within the country.
It has a recent history of meddling in the affairs of its neighbours, like the fledgling Iraq, and launched a million men and young boys in human waves against Saddam Hussein's armies dug in along the border in the 1980s.
The religious leaders of the time seemed quite happy to allow this wholesale slaughter without any sign of remorse. So the question remains, would Iran's leadership launch a nuclear strike against Israel?
Today, it cannot because the technology is not there. Will it at some time in the future if Iran were to ever develop such means?
The rest of the world can only hope that sense prevails in Tehran and the internal situation is resolved in a way that does not 'force' Ahmadinejad to take the 'nuclear option' – not literally, but by creating the conditions for war in order to reinforce his own embattled and increasingly fragile position as leader.
With Congress gridlocked on an immigration bill, the Obama administration is considering using a back door to stop deporting many illegal immigrants - what a draft government memo said could be "a non-legislative version of amnesty."
The memo, addressed to U.S. Citizenship and Immigration Services Director Alejandro Mayorkas and written by four agency staffers, lists tools it says the administration has to "reduce the threat of removal" for many illegal immigrants who have run afoul of immigration authorities.
"In the absence of comprehensive immigration reform, USCIS can extend benefits and/or protections to many individuals and groups by issuing new guidance and regulations, exercising discretion with regard to parole-in-place, deferred action and the issuance of Notices to Appear," the staffers wrote in the memo, which was obtained by Sen. Charles E. Grassley, Iowa Republican.
The memo suggests that in-depth discussions have occurred on how to keep many illegal immigrants in the country, which would be at least a temporary alternative to the proposals Democrats in Congress have made to legalize illegal immigrants.
Chris Bentley, a USCIS spokesman, said drafting the memo doesn't mean the agency has embraced the policy and "nobody should mistake deliberation and exchange of ideas for final decisions."
"As a matter of good government, U.S. Citizenship and Immigration Services will discuss just about every issue that comes within the purview of the immigration system," he said in an e-mail statement. "We continue to maintain that comprehensive bipartisan legislation, coupled with smart, effective enforcement, is the only solution to our nation's immigration challenges."
He said the Homeland Security Department "will not grant deferred action or humanitarian parole to the nation's entire illegal immigrant population."
The memo does talk about targeting specific groups of illegal immigrants.
Mr. Grassley said it confirms his fears that the administration is trying an end-run around Congress.
GUATEMALA - The trial of 14 alleged members of the Mexican drug cartel Los Zetas continued Thursday in the case of 11 Guatemalan drug traffickers killed in Zacapa department in 2008.
According to prosecutors, the killings were part of a fierce battle between a Guatemalan drug gang and the Mexican cartel Los Zetas for control of smuggling routes through Guatemala.
The clash between the two cartels revealed the presence in Guatemala of Mexico's powerful drug mafia, especially Los Zetas, considered to be the armed wing of the Gulf Cartel.
However, not all the defendants attended the hearing on Wednesday; two of them, a Mexican and a Guatemalan, remained in prison because authorities feared a rescue attempt, and they followed the hearing via videoconference.
Defense lawyers tried to suspend the hearing, calling it illegal, but were unsuccessful.
The prosecutor's office says it has more than 500 pieces of evidence linking defendants to the 2008 murders and other crimes, including illegal weapons possession, armed robbery and forgery.
