Backtalk March/April

Complicated Labor

David Goodman highlights the important subject of off-label use of prescription drugs but manages only a one-sided account of a very complex issue ("Forced Labor," January/February). The article suggests that physicians are using an unsafe drug, rather than exploring the more likely scenario that they are using a drug with an established off-label use in an unsafe manner. In fact, the tragedies of the two women presented in the article may have been a result of improper practice. Uterine rupture, fetal disability, and possible fetal death are well- known, albeit rare, complications of drugs that have been judged safe by the FDA for labor induction. These complications are more likely when the drug is used improperly.

To date, the administration of misoprostol (marketed as Cytotec) for induction of labor has been tested in at least 26 clinical trials. Its use has been judged safe and efficacious by the American College of Obstetricians and Gynecologists (ACOG) when it is used following proper guidelines. A review of MedWatch -- a service of the FDA -- indicates that a majority of the serious adverse outcomes associated with Cytotec use for labor induction occurred as a result of usage outside ACOG guidelines. In sum, most of the serious complications reported to the FDA last year likely resulted from the improper use of a safe drug and not from "vigilante" use of an unsafe drug.

It is only recently that progressive feminist researchers have understood the true potential of misoprostol as a drug for women's health and have begun to research the best regimens. Ironically, this effort has not been supported by G.D. Searle and Pharmacia, the marketers of Cytotec in 84 countries worldwide -- countries that are home to some of the world's poorest women, who might benefit most by the development of misoprostol.

Caitlin Shannon, M.P.H.
Dr. Beverly Winikoff
Shelley Clark, PH.D.
New York, New York


 

Goodman states that the FDA has received reports of 30 women who experienced uterine rupture resulting in eight perinatal deaths. The perinatal death rate for those cases was 23.5 percent -- much lower than that reported in several articles from different parts of the world in which women were induced with agents other than misoprostol. (In those trials, perinatal death rates ranged from 32 to 75 percent.) Thus, the perinatal death rate in patients experiencing uterine rupture after the use of misoprostol is significantly less than that reported with the use of other inducing agents.

Obstetricians do not use misoprostol exclusively for "physician convenience." It is used because it is very effective and safe. It not only ripens the cervix but also induces labor. Oxytocin, marketed as Pitocin, is very effective and safe as a labor-induction agent, but not at all effective as a cervical ripener. Labor induction in patients with an unfavorable cervix often results in failed inductions and unnecessary cesarean deliveries. It is our opinion, based on sound scientific evidence, that misoprostol, when used appropriately, is a safe and very effective agent for cervical ripening and labor induction.

Dr. Luis Sanchez-Ramos
Jacksonville, Florida


 

Searle's highly publicized admonition not to use Cytotec in labor was a direct result of pressure from strong antiabortion forces. Because Cytotec is used with RU-486 to induce early abortion, antiabortion forces wanted to create a circle of fear around the use of this drug in pregnancy, despite its excellent safety record. When Searle bowed to these forces, it was only looking out for its own self-interest.

Dr. Alice Rothchild
Boston, Massachusetts


 

I am so glad that Mother Jones is speaking out on controversial issues such as Cytotec. I had a 38-hour natural labor and delivery because I was well read and informed about the harmful effects of the drugs routinely administered to women during childbirth. I find it appalling that many doctors are so medically shortsighted to put lives at risk for the sake of their own egos. This article angered and disappointed me, and I will be certain to tell the women I know about its risks. Thank you for your investigative work.

Melanie McDonald
Frostburg, Maryland


 

Online Academia

As a full-time assistant professor in a small liberal arts college, I found much of your analysis of online colleges compelling ("Digital Diplomas," January/ February). At the same time, your authors need to look a little more skeptically at some of the academic voices criticizing this process. It is all well to talk about threats to the autonomy and academic freedom of college professors, but a simplistic perspective of "good prof vs. bad administrator" obscures important dimensions of what is going on. Is the increasing number of adjuncts simply a product of administrative bean counters? Or do many academics simply not wish to teach lower-level classes, which afford them little professional status? If we are to resist the negative implications of new technology, academics who care about teaching must start by acknowledging that many of our current disciplinary practices are not student-friendly. Then we might be able to talk intelligently about how we can use technology, rather than simply have it used on us.

Marc Belanger
Saint Mary's College
Notre Dame, Indiana


 

I have taught distance education courses via two-way video, and there is a push at my institution to offer more such courses, despite students' dislike of them and faculty's unwillingness to teach by this method. If the business model that colleges and universities are turning to insists that "the customer is always right," why do these institutions continue to offer distance education?

Academia repeatedly tries to circumvent the process of teaching and learning by "canning" or prepackaging education, despite data that show it to be ineffective. It failed in the 1950s, when B.F. Skinner tried unsuccessfully to create a machine to re-place teachers in the classroom. And it failed in the 1970s, when I was taught math and science via filmstrips. Here we go again!

Holiday E. Adair
California University of Pennsylvania
California, Pennsylvania


 

Global Protest

I have to take exception to Roger Cohn's suggestion ("Editor's Note," January/February) that the stakes in the current protests against globalization are not as high as those in the civil rights struggle of the last century. This time around it is not the struggle of nonwhites against the oppression of a segment of the white population in one nation, but the struggle of all people against an emergent ruling elite bent on disenfranchising everyone else.

Cecil Bothwell
Black Mountian, North Carolina


 

Mr. Wellstone Goes to Washington

I was very disappointed by "The Seduction of Paul Wellstone" (January/February). I have worked with Wellstone for many years, and no one should doubt that from his first day in the U.S. Senate 10 years ago, he has been, far and away, the most progressive member of that institution. On virtually every issue of concern to average Americans -- health care, education, workers' rights, the environment -- Wellstone's voice has been loud and clear. When progressive activists want a senator to defend their issues, they invariably turn to Paul -- for all the right reasons.

At a time when the Republican Party and corporate America control the White House, the U.S. Senate, and the House of Representatives, progressives should be spending their energy organizing the working people of this country to stand up for their rights and to take political power. That process is not helped when an excellent publication like Mother Jones wastes its pages by attacking an outstanding senator like Paul Wellstone.

Rep. Bernie Sanders
Washington, D.C.


 

Steve Perry's outrageously inaccurate discussion of Paul Wellstone strikes me as a classic instance of a writer starting with a sloppy thesis (in this instance, that participation in the real work of lawmaking in the U.S. Congress automatically equates to self- betrayal) and then trying unsuccessfully to find an individual whose actions prove his case. Wellstone has stuck out his neck repeatedly to speak up for the disenfranchised of our nation -- minorities and children of low income, in particular -- and to give their advocates the access and the public forum they have rarely been afforded by a member of the House or Senate.

Perry ignores, as well, the fervent advocacy Wellstone has provided in defense of public education and his utterly unfashionable courage in opposing the test mania that has been forced upon our schools. No possible political advantage could accrue to him as a result of his unßinching opposition to this orchestrated effort to straitjacket education.

Perry's hatchet job raises a familiar question for the left: With supposed friends like Perry, why should we fear enemies at places like the Heritage Foundation? The left, it seems, will gladly kill its own before the battles even start. I am sorry Mother Jones did not solicit some fair-minded comments before running this attack on one of the most decent and unselfish public figures in the nation and one of the few progressive heroes who has kept faith with the troops in the front lines.

Jonathan Kozol
Byfield, Massacusetts