DiversityNursing Blog

Written by James McIntosh

www.medicalnewstoday.com 

Obesity is a serious public health problem in the US and can affect anyone regardless of age. In particular, childhood obesity prevalence remains high. As well as compromising a child's immediate health, obesity can also negatively influence long-term health dramatically. Unfortunately, some racial and ethnic groups are affected by obesity much more than others.

For example, the US Department of Health and Human Services Office of Minority Health (OMH) report that African-American women have the highest rates of being overweight or obese, compared with other racial or ethnic groups in the US.

Approximately 4 out of 5 African-African women were found to be overweight or obese and, in 2011, African-American women were 80% more likely to be obese than non-Hispanic white women.

Researchers have identified that disparities in obesity prevalence can be found just as readily among children as among adults. It is alarming that these disparities exist to begin with, but more so that they exist so early in life for so many.

In this Spotlight feature, we take a brief look at the prevalence of childhood obesity in the US and the disparities in childhood obesity prevalence that exist among different racial and ethnic groups. We will examine what factors may contribute to this disparity and what action can be taken to remedy the situation.

A growing problem

"Obesity is the terror within," states Dr. Richard Carmona, the former Surgeon General. "Unless we do something about it, the magnitude of the dilemma will dwarf 9-11 or any other terrorist attempt."

These are strong words, but they illustrate the scope of the obesity problem. According to the Centers for Disease Control and Prevention (CDC), in 2009-2010, over a third (35.7%) of adults in the US were obese.

On average, childhood obesity in the US has not changed significantly since 2003-2004, and overall, approximately 17% of all children and adolescents aged 2-19 years are obese - a total of 12.7 million.

There are a number of immediate health problems that childhood obesity can lead to, including:

• Respiratory problems, such as asthma and sleep apnea
• High blood pressure and cholesterol
• Fatty liver disease
• Increased risk of psychological and social problems, such as discrimination and low self-esteem
• Joint problems
• Type 2 diabetes.

In the long term, obese children are much more likely to grow up to be obese as adults than children with healthy weights. Not only that, but the obesity experienced by these children is likely to be more severe, leading to further and more extreme health problems.

Significant disparities exist in obesity prevalence between different racial and ethnic groups. The CDC report the following obesity prevalence percentages among different youth demographics:

• Hispanic youth - 22.4%
• Non-Hispanic black youth - 20.2%
• Non-Hispanic white youth - 14.1%
• Non-Hispanic Asian youth - 8.6%.

From these figures taken from 2011-2012, we can see that levels of obesity among Hispanic and non-Hispanic black children and adolescents are significantly above average.

When the parameters are extended to include overweight children as well, the disparity persists. Around 38.9% of Hispanic youth and 32.5% of non-Hispanic black youth are either overweight or obese, compared with 28.5% of non-Hispanic white youth.

In 2008, Dr. Sonia Caprio, from the Yale University School of Medicine, CN, and colleagues wrote an article published in Diabetes Care in which they examined the influence of race, ethnicity and culture on childhood obesity, and what their implications were for prevention and treatment.

"Obesity in children is associated with severe impairments in quality of life," state the authors. "Although differences by race may exist in some domains, the strong negative effect is seen across all racial/ethnic groups and dwarfs any potential racial/ethnic differences."

However, if there are specific factors contributing to these disparities that can be addressed, the numbers involved suggest that attention should be paid to them. The long-term health of thousands of children in the US is at stake.

Socioeconomic factors

"Rarely is obesity in children caused by a medical condition," write the National Association for the Advancement of Colored People (NAACP) in their childhood obesity advocacy manual. "It occurs when more calories are eaten than calories burned."

The NAACP outline a number of factors that contribute to increases in childhood obesity, including:

• The development of neighborhoods that hinder or prevent outdoor physical activity
• Failure to adequately educate and influence families about good nutrition
• Ignored need for access to healthy foods within communities
• Limited physical activity in schools
• Promotion of a processed food culture.

The CDC report that childhood obesity among preschoolers is more prevalent in those who come from lower-income families. It is likely that this ties in with the disparity with obesity prevalence among different racial and ethnic groups.

"There are major racial differences in wealth at a given level of income," write Caprio, et al. "Whereas whites in the bottom quintile of income had some accumulated resources, African-Americans in the same income quintile had 400 times less or essentially none."

Fast food and processed food is widely available, low cost and nutritionally poor. For these reasons, they are often associated with rising obesity prevalence among children. According to Caprio, et al., lower-cost foods comprise a greater proportion of the diet of lower-income individuals.

If adults need to work long hours in order to make enough money to support their families, they may have a limited amount of time in which to prepare meals, leading them to choose fast food and convenient processed food over more healthy home-cooked meals.

Living in high-poverty areas can also mean that children have limited access to suitable outdoor spaces for exercise. If the street is the only option available to children in which to play, they or their parents may prefer them to stay inside in a safer environment.

Hispanic youth and non-Hispanic black youth are more likely to come from lower-income families than non-Hispanic white youth. According to The State of Obesity, white families earn $2 for every $1 earned by Hispanic or non-Hispanic black families.

Over 38% of African-American children aged below 18 and 23% of Latino families live below the poverty line. This statistic suggests that the effects of living with a low income that increase the risk of obesity may be felt much more by African-American and Latino families and their children.

Not only do these socioeconomic factors increase the risk of obesity among these demographic groups but equally obesity can compromise a family's economic standing.

The NAACP point out that families with obese children spend more money on clothing and medical care. Additionally, as obese and overweight girls frequently start puberty at a younger-than-average age, there is a possibility that their risk of adolescent pregnancy is also higher.

Cultural factors

Alongside these socioeconomic factors, a number of additional factors exist that may be linked to an increased prevalence of childhood obesity among Hispanic and non-Hispanic black youth.

The NAACP give one such example, stating that one component of body image is how a person believes others view them or accept their weight:

"This also poses unique challenges in African-American communities because of cultural norms that accept, uplift and at times reward individuals who are considered 'big-boned,' 'P-H-A-T, fat,' or thick.'"

Cultural norms such as these may lead to parents remaining satisfied with the weight of their children or even wanting them to be heavier, even if they are at an unhealthy weight. Other sociological studies have also suggested that among Hispanic families, women may prefer a thin figure for themselves but a larger one for their children, according to Caprio, et al.

As well as being influenced by socioeconomic status, the type of foods eaten by children can be influenced by the cultural traditions of their families.

"Food is both an expression of cultural identity and a means of preserving family and community unity," write Caprio, et al. "While consumption of traditional food with family may lower the risk of obesity in some children (e.g., Asians), it may increase the risk of obesity in other children (e.g., African-Americans)."

As mentioned earlier, the promotion of a processed food culture may be a contributing factor to childhood obesity. As fast food companies target specific audiences, favoring cultural forms associated with a particular race or ethnicity could increase children's risk of being exposed to aggressive marketing.

Caprio, et al., report that exposure to food-related television advertising - most frequently fast food advertising - was found to be 60% among African-American children.

The amount of television that is watched may contribute as well; one study conducted by the Kaiser Family Foundation observed that African-American children watched television for longer periods than non-Hispanic white children.

A number of these cultural factors are associated with socioeconomic factors. African-American children may be more likely to watch television for longer, for example, if they live in areas where opportunities for playing safely outside are limited.

What can be done?

This subject area is far too detailed to do justice to in an article of this size, but these brief observations suggest that there should be ways in which the disparity in childhood obesity between racial and ethnic groups can be addressed.

Having more safe spaces to walk, exercise and play in low-income areas would give children a better opportunity to get the exercise need to burn the required number of calories each day. Improving the availability of and access to healthy food would give families more options when it came to maintaining a healthy, balanced diet.

The NAACP state that low-income neighborhoods have half as many supermarkets as the wealthiest neighborhoods, suggesting that for many low-income families, accessing healthy food can be a challenge.

These problems are ones that would need to be solved by local government and businesses that have influence over the planning and development of public living spaces. 

Caprio, et al. propose that a "socioecological" framework should be adopted to guide the prevention of childhood obesity. Such a framework would involve viewing children "in the context of their families, communities, and cultures, emphasizing the relationships among environmental, biological and behavioral determinants of health."

This approach would require large-scale collaboration, involving peer support, the establishment of supportive social norms and both the private and public sector working together.

"For health care providers to have a meaningful interaction about energy intake and energy expenditure with children/families, providers should have training in cultural competency in order to understand the specific barriers patients face and the influence of culture and society on health behaviors," the authors suggest.

In order for this disparity to be adequately addressed, a lot of work will need to be done. Not only might certain cultural norms need to be altered, but most importantly, environments will need to be provided in which children will have the opportunity to live as healthy lives as possible.

Source: University of California - Los Angeles

Latinos are the largest ethnic minority group in the United States, and it's expected that by 2050 they will comprise almost 30 percent of the U.S. population. Yet they are also the most underserved by health care and health insurance providers. Latinos' low rates of insurance coverage and poor access to health care strongly suggest a need for better outreach by health care providers and an improvement in insurance coverage. Although the implementation of the Affordable Care Act of 2010 seems to have helped (approximately 25 percent of those eligible for coverage under the ACA are Latino), public health experts expect that, even with the ACA, Latinos will continue to have problems accessing high-quality health care.

Alex Ortega, a professor of public health at the UCLA Fielding School of Public Health, and colleagues conducted an extensive review of published scientific research on Latino health care. Their analysis, published in the March issue of the Annual Review of Public Health, identifies four problem areas related to health care delivery to Latinos under ACA: The consequences of not covering undocumented residents. The growth of the Latino population in states that are not participating in the ACA's Medicaid expansion program. The heavier demand on public and private health care systems serving newly insured Latinos. The need to increase the number of Latino physicians and non-physician health care providers to address language and cultural barriers.

"As the Latino population continues to grow, it should be a national health policy priority to improve their access to care and determine the best way to deliver high-quality care to this population at the local, state and national levels," Ortega said. "Resolving these four key issues would be an important first step."

Insurance for the undocumented

Whether and how to provide insurance for undocumented residents is, at best, a complicated decision, said Ortega, who is also the director of the UCLA Center for Population Health and Health Disparities.

For one thing, the ACA explicitly excludes the estimated 12 million undocumented people in the U.S. from benefiting from either the state insurance exchanges established by the ACA or the ACA's expansion of Medicaid. That rule could create a number of problems for local health care and public health systems.

For example, federal law dictates that anyone can receive treatment at emergency rooms regardless of their citizenship status, so the ACA's exclusion of undocumented immigrants has discouraged them from using primary care providers and instead driven them to visit emergency departments. This is more costly for users and taxpayers, and it results in higher premiums for those who are insured.

In addition, previous research has shown that undocumented people often delay seeking care for medical problems.

"That likely results in more visits to emergency departments when they are sicker, more complications and more deaths, and more costly care relative to insured patients," Ortega said.

Insuring the undocumented would help to minimize these problems and would also have a significant economic benefit.

"Given the relatively young age and healthy profiles of undocumented individuals, insuring them through the ACA and expanding Medicaid could help offset the anticipated high costs of managing other patients, especially those who have insurance but also have chronic health problems," Ortega said.

The growing Latino population in non-ACA Medicaid expansion states

A number of states opted out of ACA Medicaid expansion after the 2012 Supreme Court ruling that made it voluntary for state governments. That trend has had a negative effect on Latinos in these states who would otherwise be eligible for Medicaid benefits, Ortega said.

As of March, 28 states including Washington, D.C., are expanding eligibility for Medicaid under the ACA, and six more are considering expansions. That leaves 16 states who are not participating, many of which have rapidly increasing Latino populations.

"It's estimated that if every state participated in the Medicaid expansion, nearly all uninsured Latinos would be covered except those barred by current law -- the undocumented and those who have been in the U.S. less than five years," Ortega said. "Without full expansion, existing health disparities among Latinos in these areas may worsen over time, and their health will deteriorate."

New demands on community clinics and health centers

Nationally, Latinos account for more than 35 percent of patients at community clinics and federally approved health centers. Many community clinics provide culturally sensitive care and play an important role in eliminating racial and ethnic health care disparities.

But Ortega said there is concern about their financial viability. As the ACA is implemented and more people become insured for the first time, local community clinics will be critical for delivering primary care to those who remain uninsured.

"These services may become increasingly politically tenuous as undocumented populations account for higher proportions of clinic users over time," he said. "So it remains unclear how these clinics will continue to provide care for them."

Need for diversity in health care workforce

Language barriers also can affect the quality of care for people with limited English proficiency, creating a need for more Latino health care workers -- Ortega said the proportion of physicians who are Latino has not significantly changed since the 1980s.

The gap could make Latinos more vulnerable and potentially more expensive to treat than other racial and ethnic groups with better English language skills.

The UCLA study also found recent analyses of states that were among the first to implement their own insurance marketplaces suggesting that reducing the number of people who were uninsured reduced mortality and improved health status among the previously uninsured.

"That, of course, is the goal -- to see improvements in the overall health for everyone," Ortega said.

Emergency department nurses aren't like the rest of us - they are more extroverted, agreeable and open - attributes that make them successful in the demanding, fast-paced and often stressful environment of an emergency department, according to a new study by University of Sydney.

"Emergency nurses are a special breed," says Belinda Kennedy from Sydney Nursing School, a 15 year critical care veteran who led the study.

"Despite numerous studies about personalities of nurses in general, there has been little research done on the personalities of nurses in clinical specialty areas.

"My years working as a critical care nurse has made me aware of the difficulty in retaining emergency nurses and I have observed apparent differences in personality among these specialty groups. This prompted me to undertake this research which is the first on this topic in more than 20 years.

"We found that emergency nurses demonstrated significantly higher levels of openness to experience, agreeableness, and extroversion personality domains compared to the normal population.

"Emergency departments (ED) are a highly stressful environment - busy, noisy, and with high patient turnover. It is the entry point for approximately 40 per cent of all hospital admissions, and the frequency and type of presentations is unpredictable.

"Emergency nurses must have the capacity to care for the full spectrum of physical, psychological and social health problems within their community.

"They must also able to develop a rapport with individuals from all age groups and socioeconomic and cultural backgrounds, in time-critical situations and often at a time when these individuals are at their most vulnerable.

"For these reasons, ED staff experience high levels of stress and emotional exhaustion, so it's understandable that it takes a certain personality type to function in this working environment.

"Our research findings have potential implications for workforce recruitment and retention in emergency nursing.

"With ever-increasing demands on emergency services it is necessary to consider how to enhance the recruitment and retention of emergency nurses in public hospitals. Assessment of personality and knowledge of its influence on specialty selection may assist in improving this.

"The retention of emergency nurses not only has potential economic advantages, but also a likely positive impact on patient care and outcomes, as well as improved morale among the nursing workforce," she said.

Since this article is from Aulstralia, do you agree that Emergency Room Nurses in the US should have the same characteristics to be successful in a US Emergency Room?

Source: http://sydney.edu.au

By Associated Press

Disabilities among U.S. children have increased slightly, with a bigger rise in mental and developmental problems in those from wealthier families, a 10-year analysis found.

Disadvantaged kids still bear a disproportionate burden.

The increases may partly reflect more awareness and recognition that conditions, including autism, require a specific diagnosis to receive special services, the researchers said.

Meantime, physical disabilities declined, as other studies have suggested.

The study is the first to look broadly at the 10-year trend but the results echo previous studies showing increases in autism, attention problems and other developmental or mental disabilities. It also has long been known that the disadvantaged are more likely to have chronic health problems and lack of access to good health care, which both can contribute to disabilities.

The researchers studied parents' responses about children from birth through age 17 gathered in 2000-2011 government-conducted health surveys. Parents were asked about disabilities from chronic conditions including hearing or vision problems; bone or muscle ailments; and mental, behavioral or developmental problems that limited kids' physical abilities or required them to receive early behavioral intervention or special educational services. Nearly 200,000 children were involved.

Results were published online Monday in Pediatrics.

Overall, disabilities of any kind affected 8 percent children by 2010-2011, compared to close to 7 percent a decade earlier. For children living in poverty, the rate was 10 percent at the end of the period, versus about 6 percent of kids from wealthy families.

The overall trend reflects a 16 percent increase, while disabilities in kids from wealthy families climbed more than 28 percent, the researchers found. The trend was fueled by increases in attention problems, speech problems and other mental or developmental disorders that likely include autism although that condition isn't identified in the analyzed data.

Declines in asthma-related problems and kids' injuries accounted for much of the overall 12 percent drop in physical disabilities. Better asthma control and treatment and more use of bike helmets, car seats and seat-belts may have contributed to that trend, said lead author Dr. Amy Houtrow, a pediatric rehabilitation specialist at the University of Pittsburgh.

The developmental disability increases echo what Dr. Kenneth Norwood, a developmental pediatrician in Charlottesville, Virginia sees in his medical practice.

"I'm routinely backed up six months for new patients," said Norwood, chairman of the American Academy of Pediatrics' Council on Children with Disabilities.

Norwood thinks there is more awareness of these conditions and that some, including autism, are truly rising in prevalence. Autism is thought to result from genetic flaws interacting with many other factors. Some studies have suggested these may include parents' age and prenatal infections.

Source: www.foxnews.com

By Val Willingham and Miriam Falco

 (CNN) -- Chikungunya -- a tropical disease with a funny name that packs a wallop like having your bones crushed -- has finally taken up residence in the United States.

Ever since the first local transmission of chikungunya was reported in the Americas late last year, health officials have been bracing for the arrival of the debilitating, mosquito-borne virus in the United States. Just seven months after the first cases were found in the Caribbean, the Centers for Disease Control and Preventionreported the first locally acquired case of chikungunya in Florida.

Even though chikungunya is not on the National Notifiable Diseases Surveillance System list, 31 states and two U.S. territories have reported cases of the disease since the beginning of the year. But only Puerto Rico and the U.S. Virgin Islands reported locally acquired cases. All the other cases were travelers who were infected in countries where the virus was endemic and were diagnosed upon returning to the United States.

That ended Thursday, when the CDC reported a man in Florida, who had not recently traveled outside the country, came down with the illness.

As of right now, the Florida Department of Health confirmed there are at least two cases. One case is in Miami Dade County and the other is in Palm Beach County.

Its arrival did not surprise the chair of the Florida Keys Mosquito Control Board.

"It was just a matter of when. We are prepared in the Keys and have been prepared for some time to deal with chikungunya," Steve Smith said. "From what I am seeing, I'm sure there are more cases out there that we don't know about. It's really a matter of time."

The CDC is working closely with the Florida Department of Health to investigate how the patient came down with the virus. The CDC will also monitor for additional locally acquired U.S. cases in the coming weeks and months.

The virus, which can cause joint pain and arthritis-like symptoms, has been on the U.S. public health radar for some time.

Usually about 25 to 28 infected travelers bring it to the United States each year. But this new case represents the first time that mosquitoes themselves are thought to have transferred the disease within the continental United States

"The arrival of chikungunya virus, first in the tropical Americas and now in the United States, underscores the risks posed by this and other exotic pathogens," said Roger Nasci, chief of CDC's Arboviral Diseases Branch. "This emphasizes the importance of CDC's health security initiatives designed to maintain effective surveillance networks, diagnostic laboratories and mosquito control programs both in the United States and around the world."

The virus is not deadly, but it can be extremely painful, with symptoms lasting for weeks. Those with weak immune systems, such as the elderly, are more likely to suffer from the virus' side effects than those who are healthier. About 60% to 90% of those infected will have symptoms, says Nasci. People infected with chikungunya will often have severe joint pain, particularly in their hands and feet, and can also quickly get very high fevers.

The good news, said Dr. William Schaffner, an infectious diseases expert with Vanderbilt University in Nashville, is that the United States is more sophisticated when it comes to controlling mosquitoes than many other nations and should be able to keep the problem under control.

"We live in a largely air-conditioned environment, and we have a lot of screening (window screens, porch screens)," Shaffner said. "So we can separate the humans from the mosquito population, but we cannot be completely be isolated."

Mosquito-borne virus worries CDC

Chikungunya was originally identified in East Africa in the 1950s. Then about 10 years ago, chikungunya spread to the Indian Ocean and India, and a few years later an outbreak in northern Italy sickened about 200 people. Now at least 74 countries plus the United States are reporting local transmission of the virus.

The ecological makeup of the United States supports the spread of an illness such as this, especially in the tropical areas of Florida and other Southern states, according to the CDC.

The other concern is the type of mosquito that carries the illness.

Unlike most mosquitoes that breed and prosper outside from dusk to dawn, the chikungunya virus is most often spread to people byAedes aegypti and Aedes albopictus mosquitoes, which are most active during the day, which makes it difficult to use the same chemical mosquito control measures.

These are the same mosquitoes that transmit the virus that causes dengue fever. The disease is transmitted from mosquito to human, human to mosquito and so forth. A female mosquito of this type lives three to four weeks and can bite someone every three to four days.

Shaffner and other health experts recommend people remember the mosquito-control basics:

-- Use bug spray if you are going out, especially in tropical or wooded areas near water.

-- Get rid of standing water in empty plastic pools, flower pots, pet dishes and gutters to eliminate mosquito breeding grounds.

-- Wear long sleeves and pants.

Source: www.cnn.com

By TAMAR LEWIN

At home in Lisbon, a gay couple invited friends over to a birthday celebration, and at the end of the evening shared a surprise — an ultrasound image of their baby, moving around in the belly of a woman in Pennsylvania being paid to carry their child.

“Everyone was shocked, and asked everything about how we do this,” said Paulo, who spoke on the condition that neither his last name nor that of his husband, João, be used since what they were doing is a crime in Portugal.

While babies through surrogacy have become increasingly common in the United States, with celebrities like Elton John, Sarah Jessica Parker and Jimmy Fallon openly discussing how they started a family, the situation is quite different in Portugal — as it is in most of the world where the hiring of a woman to carry a child is forbidden. And as Paulo and João have discovered, even bringing home a baby born abroad through surrogacy can be complicated.

In an era of globalization, the market for children crosses national borders; witness the longtime flow of Americans who have gone overseas to adopt babies from South Korea, China, Russia and Guatemala.

Other than the United States, only a few countries — among them India, Thailand, Ukraine and Mexico — allow paid surrogacy. As a result, there is an increasing flow in the opposite direction, with the United States drawing affluent couples from Europe, Asia and Australia. Indeed, many large surrogacy agencies in the United States say international clients — gay, straight, married or single — provide the bulk of their business.

The traffic highlights a divide between the United States and much of the world over fundamental questions about what constitutes a family, who is considered a legal parent, who is eligible for citizenship and whether paid childbirth is a service or exploitation.

In many nations, a situation that splits motherhood between the biological mother and a surrogate carrier is widely believed to be against the child’s best interests. And even more so when three women are involved: the genetic mother, whose egg is used; the mother who carries the baby; and the one who commissioned and will raise the child.

Many countries forbid advertising foreign or domestic surrogacy services and allow only what is known as altruistic surrogacy, in which the woman carrying the baby receives payment only for her expenses. Those countries abhor what they call the commercialization of baby making and view commercial surrogacy as inherently exploitive of poor women, noting that affluent women generally do not rent out their wombs.

But while many states, including New York, ban surrogacy, others, like California, welcome it as a legitimate business. Together, domestic and international couples will have more than 2,000 babies through gestational surrogacy in the United States this year, almost three times as many as a decade ago. Ads galore seek egg donors, would-be parents, would-be surrogates. Many surrogates and intended parents find each other on the Internet and make their arrangements independently, sometimes without a lawyer or a formal contract.

The agencies that match intended parents and surrogates are unregulated, creating a marketplace where vulnerable clients yearning for a baby can be preyed upon by the unscrupulous or incompetent. Some agencies pop up briefly, then disappear. Others have taken money that was supposed to be in escrow for the surrogate, or failed to pay the fees the money was to cover.

Surrogacy began in the United States more than 30 years ago, soon after the first baby was born through in vitro fertilization in England. At the time, most surrogates were also the genetic mothers, becoming pregnant through artificial insemination with the sperm of the intended father. But that changed after the Baby M case in 1986, in which the surrogate, Mary Beth Whitehead, refused to give the baby to the biological father and his wife. In the wake of the spectacle of two families fighting over a baby who belonged to both of them, traditional surrogacy gave way to gestational surrogacy, in which an embryo is created in the laboratory — sometimes using eggs and sperm from the parents, sometimes from donors — and transferred to a surrogate who has no genetic link to the baby.

But thorny questions remain: How much extra will the surrogate be paid for a cesarean section, multiple births — or loss of her uterus? What if the intended parents die during the pregnancy? How long will the surrogate abstain from sex? If she needs bed rest, how much will the intended parents pay to replace her paycheck, and cover child care and housekeeping?

“The gestational carrier has to agree to follow medical advice, but there has to be some level of trust,” said Andrew W. Vorzimer, a Los Angeles surrogacy lawyer who advises on many arrangements that have gone awry. “Once everyone goes home and the doors are closed, there’s no way to really monitor what’s going on.”

Since the Baby M case, the common wisdom has been that the main risk for parents is the surrogate’s changing her mind. But Mr. Vorzimer, who has tracked problem cases in the United States over the years, said it was the reverse: Trouble most often starts with the intended parents. One intended mother decided, well into the pregnancy, that she could not raise a child that was not genetically hers. Another couple, after a divorce, offered the surrogate mother money to have an abortion.

Over the decades, Mr. Vorzimer said, there have been 81 cases of intended parents who changed their minds and 35 in which the surrogate did — 24 of them traditional surrogates who both provided the egg and carried the baby.

Surrogacy remains controversial, even in the United States, despite the rapid proliferation of clinics, doctors and agencies. When all goes well, supporters say, the arrival of a baby to parents with no other path to a biological child is an unparalleled joy.

Opponents tend to focus on the cases in which the surrogate suffers health problems or is abandoned by the intended parents, or in which the fetus has serious defects. Abortion politics hang heavily over the issue: Often, surrogacy involves twin or triplet pregnancies, with the possibility of selective reduction.

Critics sometimes draw an analogy to prostitution, another subject that raises debate over whether making money off a woman’s body represents empowerment or exploitation.

In Canada, as in Britain, payment for surrogacy is limited to expenses.

“Just like we don’t pay for blood or semen, we don’t pay for eggs or sperm or babies,” said Abby Lippman, an emeritus professor at McGill University in Montreal who studies reproductive technology. “There’s a very general consensus that paying surrogates would commodify women and their bodies. I think in the United States, it’s so consumer-oriented, so commercially oriented, so caught up in this ‘It’s my right to have a baby’ approach, that people gloss over some big issues.”

Germany flatly prohibits surrogacy, with an Embryo Protection Act that forbids implanting embryos in anyone but the woman who provided the egg. Ingrid Schneider of the University of Hamburg’s Research Center for Biotechnology, Society and the Environment said it is in children’s best interest to know that they have just one mother.

“We regard surrogacy as exploitation of women and their reproductive capacities,” Dr. Schneider said. “In our view, the bonding process between a mother and her child starts earlier than at the moment of giving birth. It is an ongoing process during pregnancy itself, in which an intense relationship is being built between a woman and her child-to-be. These bonds are essential for creating the grounds for a successful parenthood, and in our view, they protect both the mother and the child.”

With all that is known about adopted children’s seeking out their biological parents, other European experts say, it is wrongheaded to create children whose relationship with the woman who provided the egg or carried them will be severed.

Emotional and Financial Costs

The restrictions in many countries have been a boost for American surrogacy. For overseas couples, the big draw is the knowledge that many states have sophisticated fertility clinics, experienced lawyers, a large pool of egg donors and surrogates, and, especially, established legal precedent.

“We chose the United States because of the certainty of the legal process,” said Paulo, an engineer and scrub nurse. “Surrogacy is very secretive in Portugal. People don’t talk about surrogacy, and it’s hard to get any information. In the United States it is all clear.”

But it is not cheap. International would-be parents often pay $150,000 or more, an amount that rises rapidly for those who do not get a viable pregnancy on their first try. Prices vary by region, but surrogates usually receive $20,000 to $30,000, egg donors $5,000 to $10,000 (more for the Ivy League student-athlete, or model), the fertility clinic and doctor $30,000, the surrogacy agency $20,000 and the lawyers $10,000. In addition, the intended parents pay for insurance, fertility medication, and incidentals like the surrogate’s travel and maternity clothes.

Because surrogacy is so expensive in the United States, many couples travel to India, Thailand or Mexico, where the total process costs half or less. But complications have arisen — as in the case of a couple stuck in India for six years, trying to take home a baby boy, whom genetic testing had found not to be related to them, apparently because of a mix-up with the sperm donation.

Four years ago, according to Stuart Bell, the chief executive of Growing Generations, a Los Angeles surrogacy agency, only about 20 percent of its clients came from overseas, but now international clients are more than half. Other agencies report the same trend.

“Anyone who can afford it chooses the United States,” said Lesa A. Slaughter, a fertility lawyer in Los Angeles.

Some lawyers who handle surrogacy tell of ethical problems with intended parents from abroad. Melissa Brisman, a New Jersey lawyer who handled Paulo and João’s surrogacy, had a prospective client from China who wanted to use five simultaneous gestational surrogates. She turned him down.

Mr. Vorzimer, in California, had an international client who wanted six embryos implanted.

“He wanted to keep two babies, and put the rest up for adoption,” Mr. Vorzimer said. “I said, ‘What, like the pick of the litter?’ and he said, ‘That’s right.’ I told him I wouldn’t work with him.”

Probably the most agonizing cases, though, are those in which the intended parents and the surrogate do not agree on what to do about a fetus with severe defects.

Heather Rice, an Arizona mother of three, said her first surrogacy was “an experience so great I knew I wanted to do it again.” She had a very different experience the second time, when, after two miscarriages, a routine ultrasound showed that the 21-week-old fetus had a cleft in his brain.

“Mom walked out of the room, left me lying there, and I thought: ‘This is not my baby. I should not be dealing with this by myself,' ” she said. “But I told Mom, ‘I’ll respect your decision, whatever you decide, because this is your baby.’ A couple days later, they called and told me they didn’t want their little boy so I should get an abortion.”

With only days left before an abortion would become illegal under Arizona law, Ms. Rice found herself unwilling to kill the fetus.

“I think my motherly instincts kicked in when they didn’t want him,” she said. “I told them I just couldn’t do it. Dad told me God was going to punish me for disobeying them.”

Ms. Rice found a woman whose child had the same condition who wanted the baby. And on the 28-week ultrasound, the brain looked somewhat better. When Ms. Rice called and told the intended parents that someone would take the baby, they said they had decided they wanted him after all. At the delivery, though, the mother did not show up.

“When I called, she said Dad had been in the waiting room all night,” Ms. Rice said. “I was crying. I said he has to come in; he’s the father; he should be here. He came in, he cut the cord. He took the baby. And that’s the last I ever heard from them.”

Ms. Rice said she had no idea how the baby was doing, or even whether his biological parents had kept him.

“I found them on Facebook, and there’s no trace of him, so I think they gave him up for adoption,” she said. “I don’t know where he is, and it kills me every day.”

“I love being pregnant, but I don’t want to have any more children — oh, getting up in the middle of the night; oh, day care; oh, I’m done,” she said. “It’s great to see Thomas and Dennis with Nico, and how excited they are about twins. The money is nice, but we could manage without it, and it’s not why I’m doing this.”

Undeterred by Local Laws

For the Portuguese couple, the journey began when Paulo saw a television report about surrogacy, showing a gay couple who were unidentifiable in the shadows. The next day, he went to the television studio to ask how to find the two men. The producer would not share their names, but on rewatching, Paulo and João saw the name of the Connecticut fertility clinic.

Two years later, they were in a hotel in central Pennsylvania for the birth of their son, Diogo. His American passport had arrived. The bittersweet farewell dinner with the surrogate and her family was over, and the flight home was booked for the next day. All that was left to do was gaze at their sleeping baby, angelic in his white onesie, his starfish hands extended.

“It’s like a miracle,” said Paulo. “I cried when I saw the flight booking on the computer. I said: ‘Look, João. It’s not us two anymore. We are three.' ”

Getting to three was long, stressful and expensive, with problems at almost every turn — and one large hurdle remaining, as they apply for Diogo’s Portuguese citizenship.

After speaking to the Connecticut clinic, they chose a surrogacy agency that asked them to wire $100,000 up front. On the verge of sending the money, João decided that was too much. Without telling Paulo, he went back to his online research, and discovered complaints against that agency. Their second agency did not work, either: After months of back and forth, the agency turned them down, apparently because of concerns over their finances.

“They wasted almost a year of our time,” Paulo said.

Even with an agency they praise as responsible and responsive — an agency owned by Ms. Brisman, the New Jersey lawyer — obstacles continued. Their first donor’s eggs did not produce a pregnancy. The second had a genetic disorder that did not show up in the initial paperwork. A third produced a good supply of eggs, but after the first embryo was implanted, the surrogate miscarried. Their next surrogate did not get pregnant on the first try.

Through it all, the bills mounted. João and Paulo said they planned to burn them so their son would never have to think about the price, which they acknowledged was hundreds of thousands of dollars.

They have also decided not to answer any questions about which of them is the father — embryos that were inseminated by each were implanted — unless Diogo is the one asking.

“The information belongs to him,” Paolo said.

In the end, their warm relationship with the woman who bore their child was about the smoothest part of the process. The night before they were to take Diogo home, she sent an emotional text: “I know I’m doing well because I haven’t cried yet,” she said. “But I know I will.”

João and Paulo, like most international couples using an American surrogate, want their baby to be a citizen of their home country. But many Chinese parents take a different tack, keeping the American citizenship automatically conferred on every baby born here. Some hope the baby will attend an American university or help the family to live and work in the United States. But for Chinese clients, too, overseas surrogacy carries a complication, making it difficult for the baby to get a hukou, or household registration card, granting access to local schools and hospitals.

And there is another issue in China: restrictions on the number of children per family. Some Chinese couples, particularly older couples, turn to American surrogacy for a second child, whose American citizenship might clear the family from scrutiny.

But most surrogacy agencies say they will work only with intended parents who cannot carry their own baby, as recommended by the guidelines of the American Society for Reproductive Medicine. So Chinese clients who seek an overseas surrogate to get around the one-child rule create a dilemma.

“We usually only take clients who have a medical need for surrogacy, but in December, we decided to bend that rule, for Chinese people, government officials, who would be in trouble if they break the one-child rule,” said Karen Synesiou, chief executive of the Center for Surrogate Parenting, in Encino, Calif. “We’re thinking of it as political surrogacy.”

Then, too, agencies and lawyers say, there has been a recent uptick in the number of clients seeking “social surrogacy” — that is, having someone else carry their baby so as not to damage their career, or their figure. And not all agencies follow the guidelines.

“We don’t feel like we should be the gatekeepers when it comes to that,” said Saira Jhutty, chief executive of Conceptual Options, a California agency.

Final Hurdles at Home

For all the intimacy of carrying a baby for someone else, there is no template for the relationship between intended parents and the woman who will bear their child. Most contracts contain a clause requiring confidentiality unless both parties agree otherwise. And most stipulate that there will be an abortion if the fetus has serious defects, or a reduction in case of triplets or quadruplets. While no court would force a woman to have an abortion, lawyers say, a surrogate who refused to honor the agreement, and proceeded to carry a baby to term against the intended parents’ wishes, could perhaps be made to pay the costs of rearing the child, under the legal concept of wrongful birth. As surrogacy spreads, lawyers say, litigation over such issues may erupt.

For those from abroad, getting an American-born baby home can involve tangled immigration problems. Some countries require a new birth certificate, a parental order or an adoption. Some will not accept an American birth certificate with two fathers listed as the parents. Occasionally, a baby can be denied entry into the parents’ home country.

But international law is catching up with social practice: On June 26, in a case involving two sets of children born to American surrogates, the European Court of Human Rights ruled that France had violated the European Convention on Human Rights, and undermined the children’s identity, by refusing to recognize their biological father as their legal parent, easing the way to French citizenship.

The decision will most likely smooth the path for Paulo, João and their son, who entered Portugal on his American passport. So far, efforts to register Diogo in Portugal have failed, because the Portuguese process requires that a mother be named. Meanwhile, they have been advised to seek a residence card for him.

“They told us to wait three months for an answer,” Paulo said in a recent email. “We still do not know how this will end.”

Source: nytimes.com

By Sophie Quinton

Isabel Barradas, 48, has been a doctor for 25 years. In her native Venezuela, she was an orthopedic surgeon and head of a hospital department, with expertise in physical rehabilitation. She speaks three languages and—since marrying an American and moving to South Florida more than a decade ago—is a U.S. citizen.

Barradas passed her U.S. medical licensing exams with flying colors. But she didn't get a residency position in the specialty she loves. "Orthopedic surgery? Forget it. In this country, that is so elite," Barradas says. Competition for the training positions required for medical licensure is fierce, and most go to seniors at U.S. medical schools. Barradas decided that the position she did get—internal medicine in Buffalo, N.Y.—wasn't worth leaving her family in Miami for.

Thousands of foreign-educated doctors living in the U.S. would like to practice medicine here but don't have the time, money or language skills to compete for and complete a residency. Miami's Florida International University offers other options: accelerated programs leading to a bachelor's and master's of science in nursing which train foreign-educated doctors to be nurse practitioners. FIU's programs both give internationally educated professionals an outlet for their skills and helps add much-needed diversity to the health care workforce.

The U.S. faces a dearth of 20,400 primary care physicians by 2025, according to federal statistics. The Association of American Medical Colleges projects a shortage of thousands of surgeons and other specialists too. While an aging population and health insurance expansion increase demand for health care services, medical schools and residency programs aren't producing enough doctors to meet demand.

There are thousands of foreign-educated doctors living in the U.S. who have the expertise needed to address some of this growing need. Every year for the past decade, between 5,000 and 12,000 foreign-educated physicians who have passed their licensing exams apply for a residency position. Typically, about half get one, compared with more than 90 percent of U.S. medical school seniors who apply, according to data from the National Resident Matching Program.

International medical school graduates, like minority doctors, often go on to serve medically underserved populations. Graduates of international medical schools make up a quarter of U.S. office-based physicians, and are more likely than their U.S.-educated peers to treat minority patients, foreign-born patients, patients who speak little English and patients who qualify for Medicaid, according to a 2009 study from the Centers for Disease Control and Prevention.

Demand for highly trained nurses is also growing, particularly for nurses who speak more than one language and reflect the growing diversity of the U.S. population. If highly trained professionals like nurse practitioners and physician assistants were to take on more primary care responsibilities, the shortage of primary care doctors could be cut by more than two-thirds, according to the Health Resources and Services administration.

FIU introduced its accelerated nursing degree program in 2000, in response to pressure from underemployed Cuban doctors living in the area. The FEP-BSN/MSN program began as a bachelor's degree program that prepared students to become registered nurses. In 2010, FIU added a master's degree, and graduates of the full program can now find work as nurse practitioners—an advanced role that can include prescribing medicine and diagnosing patients. In Florida, nurse practitioners earn about $86,800 per year. Barradas hopes to find work with an orthopedic surgeon.

Isabel Barradas (left) and Mariana Luque, trained and credentialed as physicians in their native Venezuela and Colombia respectively, are nursing students at Florida International University. (Sophie Quinton)The program compresses six years of education into four, mostly by moving quickly through undergraduate-level material. English language learners get help with reading and writing academic papers, and courses are scheduled in the evenings or compressed into one day a week to fit the needs of working adults. For the past few years, the graduation rate has been close to 100 percent.

Despite its South Florida roots, the program has begun to attract students from all over the U.S. "I ask them, why don't you just go to the accelerated program where you live? And it's not the same for them," says Maria Olenick, program director. "They choose to come here because they know that there are other people in the same situation."

Most of the 200 doctors enrolled in FIU's program this year are bilingual. About 39 percent are from Cuba, 28 percent are from Haiti, and 6 percent are from Colombia, with the rest hailing from Nigeria to Lithuania. Students are evenly split between men and women, and the average age is about 40. Applicants must be U.S. citizens or permanent residents.

Some doctors are initially reluctant to enter a nursing program, Olenick says, fearing loss of prestige, but usually the negative feelings don't last. "What we're hearing from them is that they're actually really, really enjoy the role of nurse practitioner in the United States, because it's more like the way they practiced in their home countries," she says. American physicians tend to spend less time with patients and more time processing paperwork than their counterparts overseas. Barradas' patients in Venezuela used to come by just to chat.

It's not always easy for graduates of the accelerated degree program to find the kind of work they want, says Carlos Arias, chief operating officer of Access Healthcare. Although they're armed with an advanced nursing degree and have medical training, graduates are often offered entry-level positions with low salaries. Arias, a Cuban-educated doctor himself, now heads a Florida independent practice association that has hired two graduates of FIU's program to date.

Not all graduates choose to enter the workforce right away. The first class of nurse practitioners graduated last summer, and of 55 graduates 12 returned to FIU to enroll in a doctoral program. "We're looking now at making the program a BSN to DNP program, because we have so many that are interested," Olenick says of the doctoral program. "The way that nursing is moving, eventually a DNP will be required to practice as a nurse practitioner."

For the foreign-educated physicians in the program, the doctorate offers another perk. As a graduate, you get to be titled Dr. again.

CORRECTION: An earlier version of this article misspelled the name of Carlos Arias. It also omitted the number of graduates who returned to FIU to enroll in a doctoral program. Twelve did.

Source: NationalJournal

BY SCRUBS EDITOR 

Where in the U.S. are new nurses receiving the highest pay? Here’s a look at the numbers from some of the major West Coast cities. Keep in mind that the facts and figures are mostly related to new nurses, and numbers might be higher for nurses with more experience or for those in specific specialties.

Average pay (per hour) for top cities:

Los Angeles, CA: $36
San Francisco, CA: $34
San Diego, CA: $33
Portland, OR: $31.50
Las Vegas, NV: $30
Seattle, WA: $29
Phoenix, AZ: $29
Boise, ID: $25
Salt Lake City, UT: $24

Source: Nurse Zone

What nurses are saying about working in top cities:

Portland, OR:

“Portland is saturated with new grads. It takes most people several months to find something, and many of my classmates are moving out of town to find work. I think if you can move to a more rural area, your chances would be better to get a job faster. Quite a few of the recent grads from our school have gone the SNF route, hoping to break into hospital nursing eventually. However, if you don’t have your BSN, as a new grad, chances are slim at getting hired in a hospital here.” - pdxmomazon

“Kaiser West is supposed to open in August 2013. Hopefully more positions will open up then.” - tritons09

Los Angeles, CA:

“If you can, get 2 years experience before moving here. Or at the very least, do not move here unless you have an official job offer in hand. The job market is also tight for experienced nurses as well, and for some places a year may not cut it. Best of luck.” - meriwhen

“Job outlook in LA is bleak. Better than NoCal, but still bleak. CHLA new grad residents start in high $20s. UCLA is $30-ish for their new grad residents. So, assuming you come to LA with a year experience under your belt, you could expect more than $30ish.” –  perioddrama

San Diego, CA:

“San Diego is a great market! I’m a case manager at Scripps here and hire approx 4-5 new grads a week. Nobody should become a nurse to get rich. We work in a field where battling against the odds is no stranger to us. California does have a little tougher time with hiring nurses faster than EVERY other state but this is due to the very large budget deficit that prevents millions in grants to hospitals. I would encourage you to pursue.” - Murseman83

“It is an absolutely terrible job market for new grads in all of SoCal. I’ve heard San Diego and San Francisco are the hardest to find jobs. The job market has been bad for at least 5 years so there is no way to guess when it may get better. If you want a new grad nursing job you will have to search high and low and make it your full time job. I applied for about 150 jobs in 6 months before I got hired, 7 months after I got my license and my commute totally sucks and the pay is just okay.” - SoCalGalRN

San Francisco, CA:

“According to students who graduated from my school last year, you can make anywhere from $38-$44/hr. My friend who has been working for Kaiser for 3 years made $97K last year. That’s partly why it’s so hard to get a job as a new grad here! I graduate this year and it is SO frustrating to think that those of us who have our lives here and went to school here may not get jobs. New grad programs are smaller or non-existent. It used to be that the place you precepted would hire you but so many hospitals/units are on hiring freezes that they aren’t even looking at new grads. I know people who graduated last summer who still haven’t found work; some moved to southern California.” - lovethepeople

“I’m a new grad who was fortunate enough to find an RN position at a hospital here in the Bay Area. I’m per diem, hourly wage is $62/hr, no benefits (I buy my own private health insurance). I’m only scheduled 4 days/week and get cancelled A LOT because I have the least seniority. Just to give you an idea, during orientation, when I actually did work 36 hours/week, I was taxed almost $3K per month, federal and state income taxes. That’s 3x what I pay rent, for a studio apartment! So yeah, I know it seems like a lot, but in reality you get taxed SO much it’s probably pretty comparable to other areas in terms of take home pay relative to cost of living. The sunshine sure is nice, and the Mediterranean climate, but it does come at a premium!” - shelbel

Las Vegas, NV:

“I have lived in Las Vegas for almost 9 years. I moved here when it was booming and it was very easy to find work. I hated it the 1st year I moved here but it grew on me. Unfortunately, the job market has changed drastically since the economy has gone down the toilet. I know it is bad everywhere, but our job and foreclosure rate is the worst from what I’ve heard.” - Tree5981

Seattle, WA:

“I live in the Seattle area now, came as a travel nurse originally. Where I work we had quite a few people move here for jobs or converted from travelers to staff over the past few years. At least where I am the staff is very inclusive, and do things outside of work together quite a bit. You could always look at travel nursing to come out this way, if you didn’t want to move right out. Tonight at work, 4 out of 6 nurses moved within in the last 5 years alone to the area.” - missnurse01

Boise, ID:

“Boise is a great place to live. We have quite a few hospitals in the area that you could possibly work at. My mom is an RN at St Luke’s and loves working there.” - Ryan

“As far as negotiating sign-on bonuses go, as far as I can tell, around Idaho they are pretty locked in to what you get will be what they offer. That being said there is a little wiggle room with bonuses during negotiating if you don’t need health insurance, or have special skills being searched for by that company.” - frixion

Phoenix, AZ:

“I’ve come across several postings fairly recently from new grads wanting to move to the Phoenix area and I want to make them aware that the job market here is very competitive. Unless you are an experienced nurse, have great luck, or a strong hospital contact, new grad hospital positions are very hard to come by. I know several that have had to leave the area to find jobs. I’m not trying to be a downer, but in this economy Phoenix is NOT the place a new grad wants to be.” - dream’n

“I found that in AZ, even if you are working for a registry that is used frequently for your specialty, you have to work in each place enough that the people who call the registries know your name. There are dozens of registry nurses, so when you are not well known the best thing you can do is accept as many shifts as you can work at a variety of settings, and then if they need someone for a double shift, stay. Let the facility know that you are available for the next night if you are. You can’t book your own hours, but continuity of care and convenience actually matter, and they will try to get the same person as much as they can. If you are at a large facility, and you let them know that you are looking for more shifts, they will usually oblige.” - psychaz

Salt Lake City, UT:

“Utah is overwhelmed with nurses and it’s a right to work state so no unions. When the nursing shortage hit there was a boom of schools becoming accredited to handle the load. Every semester hundreds of nurses are released into the workforce. There is no reason for any place to pay a great wage when the pool of nurses to pick from is so vast. This also means the employers do not have to make an investment in their staff because there are literally hundreds in line needing a job. Home health agencies are popping up like crazy; they pay the highest wage and jobs are definitely available there.” - St_Claire

“Yes average is $21 an hour. Typically no you will not get paid more for having a bachelors degree although I believe that IHC prefers it to increase their “magnet status.” (That last part may not be correct.) $62,000 a year average is probably correct because nurses start out around $45,000 while veterans are probably up to $75,000 so $62,000 is somewhere in the middle. The pay in Utah is awful. If you love the state that much, people will stay and accept it. I moved 100 miles away out of state and made double that as a new grad. It’s all about where you want to live. My plan is to work out of state for a few more years and save up enough money that if I want to move my family back to Utah it will offset the ridiculously low wages.” - surgery182 

Source: Scrubs Mag