Current Events in February 2009

I weaved my way across the Indian street, dodging traffic that was so random as to be fatalistic. The fumes sent up from the adulterated petrol were fast turning my mucous black and had in fact tarnished the signs on the building opposite. Squinting I could just about make out "Ajay Jain, Dental Surgeon" followed by some indecipherable initial letters as proof of qualification.

Sparks fell from an electricity pole overhead in a tangle of wires that would have made any American electrician faint. I hopped over a stagnant puddle and onto the staircase of the building which looked like it had never been cleaned in living memory. The walls smelled of human urine and by the time I reached the rubble-strewn balcony, I was beginning to wonder if the friend who had recommended I come here for my molar cavity was having a good laugh at my expense.

I knocked timidly on the door bearing a plaque with the name Jain and it swung open to reveal a gleaming white dental surgery. The floor was tiled and kept immaculately clean, air conditioning chilled the sweat on my forehead and there was a little table of magazines to read while waiting for one's appointment.

That was my first experience of seeking medical help abroad back when I was 19. I had the choice between seeing a local specialist or going back home. I tried my luck and found treatment as friendly and professional as in the West and half an hour of dental work cost me a grand total of 400 rupees — $10.

In 2007, 750,000 Americans also concluded that it was cheaper and faster to get medical attention abroad and that number was expected to double for 2008. To get an idea of how much money they hoped to save, check out the numbers from the report by Udaily, a publication of the University of Delaware:

"The cost of surgery in India, Thailand or South Africa can be one-tenth of what it is in the United States or Western Europe, and sometimes even less. A heart-valve replacement that would cost $200,000 or more in the US, for example, goes for $10,000 in India — and that includes round-trip airfare and a brief vacation package. Similarly, a metal-free dental bridge worth $5,500 in the U.S. costs $500 in India, a knee replacement in Thailand with six days of physical therapy costs about one-fifth of what it would in the States, and Lasik eye surgery worth $3,700 in the US is available in many other countries for only $730. Cosmetic surgery savings are even greater: A full facelift that would cost $20,000 in the US runs about $1,250 in South Africa."

And then there's the time factor; while a patient might wait a year for a hip replacement in the U.S., an operation could in theory be scheduled the day after arrival in the Phillipines and many other venues.

It comes as a surprise to many that Americans should need to travel to get medical treatment. The flashing images of wealth and glamour on MTV have convinced the locals in poorer parts of the world that everyone in America is rich.

"Everyone is having at least one swimming pool there," an Indian cigarette seller once told me with great authority. When I told him about the Americans who couldn't even afford health insurance he looked at me as though I was trying to pull the wool over his eyes.

Even for me it was a hard one to swallow when I first came to the U.S. Growing up in Britain, health care was always free and like most Europeans, I pretty much took it for granted. If I ever got seriously ill I always knew that I could just head back home and get diagnosis the next day. I couldn't imagine how Americans would experience any less security or care.

Then I met someone from Oregon who, unable to afford insurance or a trip to the dentist when pain struck, had taken out a rotten tooth with a pair of pliers. The same kind of thing that happens all the time in the Third World.

Big savings

Barack Obama won early support for his promises to reform health care in the U.S. and time will tell if he manages to deliver. But with American medicine plagued by Big Pharma sales reps, litigation and prohibitively high costs, a medical vacation to Mexico or Panama can save a family a lot of money.

Waiting for my luggage once in Guadalajara airport, I got chatting with an engineer from New York who had flown down with his teenage daughter so that she could get some corrective laser treatment for her eyesight.

"Look," he said, "I could have paid thousands of dollars to get her treated back home but instead we can get it done here for like a third of the cost — and we get to have a vacation together!"

The prospect of our health going wrong is one of the scariest out there. Debilitated by pain, we'd be unable to work and so unable to pay for treatment. Many American travelers that I've known on the road, however, have taken a rather more fatalistic approach.

"I don't even have insurance," one told me, "If I added up all the money that I'd be giving to some greedy company — and who knows if they'll find something in the fine print to avoid paying up — I could just book another flight somewhere warm and get treated there instead."

It sounds good

The thing about medical tourism is that it all looks good on paper. You save a lot of money, you get treated fast and it's an unexpected opportunity to go somewhere exotic. But believe it or not, when something goes wrong with your body, you're unlikely to be in the mood to soak up a foreign culture.

Bangkok is a center for medical tourists who come for plastic surgery, knee replacements and dental work and when I spent a month in the city doing some business, I got to know a few of them. They were easy to spot amid the other backpackers — whereas the other travelers skipped around with bright eyes on their big adventure abroad, planning river trips and island hopping, these poor souls had nothing more to look forward to other than the next appointment.

I took a cold coffee with one woman from Los Angeles who was there to do some cosmetic work on a disfiguring scar that ran down her left cheek, the result of a car accident. Whereas back home no one mentioned her injury, here she was asked a thousand times a day what had happened, a fact that did nothing to calm her nerves as she waited for the day of the operation. She was alone with no moral support, other than long-distance phone calls to a boyfriend back home, and had little in common with the other westerners who had only partying on their minds.

I could relate to her. Only a couple of years before I was living in Brazil when I found myself suddenly alone and ill; one night as I went to sleep I started getting lights flashing behind my eyes and experienced a kind of electric shock in my head. I put it down to the stress of living in Rio de Janeiro and moved to a village along the coast to chill out. The symptoms persisted though and I started to get seriously worried.

I saw a couple of Brazilian neurologists but although I spoke Portuguese and their English wasn't bad, it was miserable to be discussing my health in a second language. Worse, it was terrible balancing up the options available to me without friends or family around to talk it through with. So one day I dropped everything and flew home to see a doctor I knew I could trust. There was no price I could put on that.

Why is it cheaper?

It's also worth asking yourself just why medical treatment is cheaper abroad. It's not that the quality of attention is any less — at least not if you're sensible and make sure your chosen clinic is accredited by an independent body like the Joint Commision International — but other factors come into play.

Other countries may have quite distinct legal and working practices than you would find back in the U.S. Litigation, for instance, may be the bane of professional life in America, but at least it is an option. Suppose for instance, that your operation in India goes wrong — trying to sue a doctor there would be seriously injurious to your health, the case quite probably outliving you.

And whereas the quality and competence of doctors abroad is often every bit as good as in the U.S., you'll occasionally encounter a fairly flexible set of ethics. I remember reading a scandal in the Indian newspapers a couple of years back when doctors had been caught referring their patients for heart bypass operations when there was actually no need. They had simply been getting kickbacks from the surgeons.

Medical tourism is a growing industry and professional attention can be found abroad for just about anything from cardiology to plastic surgery to joint replacements. From Panama to South Africa, Turkey to Thailand, poorer countries welcome visitors in search of treatment with open arms and, while I heard local Thais complain that all their best doctors were busy treating the falangs, no serious harm is done by it.

The other side

There is, however, another side to the story that brings out some of the biggest ethical questions of all.

Despite the best efforts of donor agencies, across the Western world there is a shortage of organs for transplants. In an aging population, by the time donors die their organs are generally in less than top condition. So there you are: you need a liver transplant and the 6-month waiting list might prove fatal; a company in China claims they can perform the operation the day after you arrive — just how many questions would you ask about where the organ comes from?

In countries like China and India, human life is cheap. Street children go missing all the time and are dumped back on the streets minus a kidney. The same can happen in state hospitals where doctors can augment their income by taking advantage of an anethetized patient.

If it's hard to believe that humans could stoop so low, take the case reported by the British newspaper, the Guardian, when they exposed the business in organs from executed political prisoners. The company concerned advertised that, "Viscera providers can be found immediately!" — some poor enemy of the regime executed to supply a fresh heart for a customer from abroad.

Even when people have parted with a kidney voluntarily, it's often for a pittance, many ending up with less than a thousand dollars. They may have been promised more but were then cheated and they may have lacked the education to understand how their health might suffer after such an operation.

We, as patients, are assured that the organ came from a willing, well-paid donor and, as we're unlikely to ever meet the poor sod, we give the clinic the benefit of the doubt. After all, we want the transplant.

Sentiment against so-called "medical tourists" is rising in some countries that have made a business out of providing transplants and other surgeries to wealthy foreigners while, in many cases, their own citizens make do with substandard care.

Even China, which sometimes seems willing to do just about anything, is having second thoughts. It has banned all organ transplants for foreigners while it investigates reports that 17 Japanese tourists received illegal kidney and liver transplants while 1.5 million Chinese languished on waiting lists.

Hidden costs

In short, the smart consumer should always look for the hidden costs.

Yes, a vital operation can be arranged abroad cheaply but will it be traumatic to undertake something so important in a foreign setting? Yes, cosmetic surgery is cheap in South America but will we really start following the example of the Argentines and buying breast enhancements as presents for our teenage daughters? And yes, a life-saving organ can be found at short notice in Asia — but can we live with ourselves if we don't know where it came from?

Whatever the ethical and emotional issues surrounding medical tourism, it's clear that it's only going to increase. In a globalized world we'll always head for the cheapest and fastest option. It was director Jim Jarmusch, however, who noted that of the three qualities cheap, fast and good, you could only ever hope for two of them at a time.

---

Tom Glaister is the author of children's books www.bozoandthestoryteller.com and is also the founder and editor of www.roadjunky.com - The Online Travel Guide for the Free and Funky Traveller.

The nation's credit crisis and deepening recession has put more and more consumers in debt and increased their vulnerability to companies making big promises about debt relief but who deliver very little.

In November 2007, Regina Bays of South Charleston answered her telephone and heard a recorded message from a company guaranteeing to reduce her credit card debt by at least $2,500.00. At the end of the recording she was connected with a salesperson for PDM International, Inc., who promised to send her additional written information about the debt relief program.

Although she was interested, Ms. Bays did not sign up for the program. Nonetheless, she later learned that PDM of Bedford, Texas, had charged her credit card $990.00. When Bays was unable to cancel the service, she filed a complaint with West Virginia Attorney General Darrell McGraw's Consumer Protection Division.

McGraw says his office has entered into a settlement with PDM that will result in refunds of $35,345.00 for 38 West Virginia consumers. In addition to PDM's questionable promise to reduce consumers' credit card debts, McGraw's office also alleged that PDM was engaging in telemarketing sales without a business license or surety bond as required by state law. Importantly, PDM did not give consumers an unconditional right to cancel at least seven days after the telephone sale, as required by West Virginia law.

"Consumers should always be wary of telephone calls from strangers who offer products and services that sound too good to be true," McGraw said. "Thanks to the complaint of Regina Bays, my office was alerted to PDM's practices and we were able to obtain refunds for all aggrieved consumers."

A ConsumerAffairs.com investigation about the new ban on chlorofluorocarbon (CFC) albuterol inhalers — and the problems many consumers are experiencing with the environmentally-friendly hydroflouroalkane (HFA) inhalers — has generated an outpouring of response from asthma patients nationwide.

There have been no expressions of concern from the government officials who imposed the switch and no hint that anyone plans to do anything to provide relief to frightened asthma patients. And organizations that supposedly represent the interests of asthma victims say patients need to get used to the new inhalers.

Since Part 1 of this series appeared on Sunday, we've heard from scores of asthma patients who are outraged by the government's decision to ban the "rescue" inhalers they rely on and force them to use a new type of inhaler they say doesn't give them any relief.

One woman even told us her daughter died after using an HFA inhaler.

"She was not sick and was not doing any activities that were not a part of her regular routine," says Maureen H. of Marengo, Ohio. "She was 26 years old and had been diagnosed (with asthma) when she was three. She was not a rookie at managing her asthma. She had an attack on Feb. 25, 2007, and died. We know without a doubt that the HFA inhaler contributed to her death. Someone must help the folks who are suffering ill effects from these new inhalers."

Many patients now fear they may die without their CFC "rescue" inhalers.

"I am very worried about not having CFC inhalers available, dying and leaving my two sweet young children motherless," Melissa L. of New York City, told us. "Within three weeks of starting the new HFA inhaler, my normally well-controlled asthma became scarily severe. The FDA has clearly made a mistake in its safety assessment of HFA propellant."

Another asthma sufferer who read our investigation called the ban on CFC inhalers "criminal."

"A travesty"

"This is a travesty of untold proportions," says Kathleen W. of Scottsdale, Arizona. "To take away viable effective medication that is vital for saving the lives of pulmonary patients is insane, inhumane, and criminal."

As we reported, metered-dose CFC inhalers are — as of December 31, 2008 — banned in the United States under an international agreement, the Montreal Protocol on Substances that Deplete the Ozone Layer.

The Food and Drug Administration (FDA) — and other agencies supporting the 1987 agreement — say the CFC propellant in the inhalers damages the earth's ozone layer.

"CFCs reduce the amount of ozone in the ozone layer that surrounds the earth and protects the earth against the sun's harmful rays," the agency wrote. "The loss of ozone can increase the risk of skin cancer, cataracts, and other harmful rays."

Asthma and other pulmonary patients must now use an environmentally friendly — and more costly — type of inhaler that contains a propellant called hydroflouroalkane (HFA).

The FDA says HFA inhalers have a different feel and taste — and patients need to take deep breaths when using them.

But the HFA "emergency" inhalers give patients the same dose of albuterol as CFC inhalers and are a "safe and effective" alternative for the more than 40 million asthma and pulmonary patients nationwide, according to the FDA.

Lung Association's stance

A spokesman for The American Lung Association also told us the HFA inhalers now on the market — ProAir, Proventil, Ventolin, and Xopenex — are just as effective as the CFC inhalers when properly used.

But the key issue, he said, is for patients to get their asthma under control

But the more than 100 patients who have contacted us say their asthma was under control until they tried the new HFA inhalers.

They also told us:

• The HFA inhalers don't give them quick relief;

• In some cases, the HFA inhalers made their asthma worse. Some say they're allergic to the ethanol in the HFA inhalers;

• HFA inhalers are more expensive than CFC inhalers. The price has skyrocketed from about $5 for a CFC inhaler to around $50 for an HFA inhaler. That's because there is no generic alternative for HFA inhalers;

• Many are not convinced CFC inhalers harm the ozone. They also say they're environmentalists, but believe the government picked the wrong product to ban;

• Many wonder why people can't choose which type of inhaler to use. They understand some patients don't have problems with the HFA inhalers. But what about those who do? Why can't they use their old CFC inhalers?

A pharmacist in the Midwest told us his patients have raised similar concerns. "My customers are not happy," says Pete Spalitto, owner of Spalitto Pharmacy in Kansas City, Missouri. "I don't anyone who is happy with these (HFA inhalers). They just flat out don't want them — young, old, middle-age. Moms don't like them for their kids. Our customers can't stand them."

He adds: "The albuterol (CFC) inhalers immediately opened up the lungs for people who had asthma, emphysema, and bronchitis. When you're gasping for air, you like to feel that inhalation going in. But people don't feel that with this new (HFA) inhaler."

Since our story ran, we've received an overwhelming response from asthma patients who echo those sentiments. In fact, we haven't heard from a single patient who supports the ban on CFC inhalers or says the new HFA emergency inhalers are an effective alternative.

Consider some of their comments:

• "I suffered a serious allergic reaction to the HFA Albuterol Sulfate inhalers (two different brands)," Judy F. of Broomfield, Colorado, told us. "The inhalers were also ineffective in relieving my asthma;"

• "Like the people in your article, I have COPD and asthma," says 52-year-old Bob D. of Wyandotte, Michigan. "I did manage to stock up on a couple of CFC inhalers before the ban, but I am having to try to stretch them out and am using the HFA inhalers as much as possible. I echo the sentiments that they do not work. I have heard and tried all the explanations and helpful tips, but they do not work. My doctor, who has asthma, agrees with me. But he feels as helpless as I do. I can no longer go about my routines like I used to.I worry that I will soon have a heart attack or cardiac arrest;"

• "The HFA inhaler fails as a rescue device, which is after all the only use of albuterol consistent with good asthma management," says Roger D. of Chicago, Illinois. "This new inhaler is going to kill somebody - hopefully not me;"

• "My son needed a new inhaler for his asthma," says Cindy Crockett of Raleigh, North Carolina. "We tried three different HFA inhalers--each at $20 co-pay instead of $10. They simply do not work as well. He has had asthma for 15 years and the problem is not because he doesn't know how to use the inhaler. It just doesn't work as well. I worry that if he has a really bad attack, he will end up in the hospital. (The damage) from this is several extra and more expensive co-pays;"

• "I have had asthma for about 30 years and COPD for the last 15," says Amanda Otero of Lincoln, California. "My asthma has always been well controlled with medications and inhalers, including CFC albuterol inhalers. I lead a very active life. A few months ago my doctor switched me to ProAir HFA inhaler. My asthma immediately became worse I could not breathe. I went back to the CFC inhalers and have had no problems since. I have a supply on hand, but live in fear of what will happen once they are gone. How can the FDA condemn so many asthmatics to this fate? Why is there not a mercy clause in this law that allows those for whom the HFA inhalers do not work to continue using the CFC's, especially when the FDA has stated that the damage done to the ozone layer by inhalers is negligible? Something has to be done to right this wrong;"

• "The HFA inhalers do not work for me," says Jen of Enfield, New Hampshire. "They have made my asthma 100 times worse than it has ever been. This is such a helpless feeling that our government would take away a life-saving medication for the label of going green. It feels like genocide. I am only 35 and I have a 2-year-old son and a 3-year-old daughter. I live in constant fear that one of them could develop asthma and have no effective medication available for them. I don't know how the FDA or the American Lung Association can turn a blind eye and keep saying the HFA inhalers are just as effective as the CFC ones. It is absolutely disgusting and unforgivable. They are killing people, and the government is watching it happen;"

• "These new HFA Inhalers do not work," wrote Ryan W. of Burbank, California. "We need our Old CFC inhalers back. I almost died."

"On the radar"

The Asthma and Allergy Foundation of America (AAFA) told us today that it's heard similar concerns from patients. And it's keeping this issue on its radar.

"We continue to hear from patients and review the information we are getting," said Charlotte Collins, the foundation's director of public policy and advocacy. "We have not done a stand-alone survey (on this). That's not outside the realm of responsibility, but that really is the place of the FDA. We've advocated for (the FDA) to do some surveying to make sure what's going on with patients as a result of this transition."

How is the foundation helping patients cope with this change?

It says it's using a three-prong approach: listening to patients' concerns, reminding them to keep their asthma under control, and educating them through its Web site about the mandatory switch to HFA inhalers and the different types of options available.

"The bottom line is that asthma patients need to make sure they're getting their asthma under control," Collins said. "If they're having trouble with these (HFA) inhalers, they need to get with a specialist to find alternatives."

AAFA officials also applauded our investigation for bringing this issue to the public's attention.

"We need to hear these things," said spokeswoman Angel Waldron. "I'm glad you're educating readers about this so there can be more discussion. This transition is happening and we're trying to learn how we can help patients cope with this change. For now, we have to figure out a way to make this (ban) work so people get the relief they need."

She added: "This is a hard issue. We, as a society, are trying to go green and make our air, our planet, safer for our kids and grandkids. The important thing for patients (who are having problems) to remember is none of the medication has changed. The only thing that is different is the way in which it is propelled. We understand patients' concerns with this, but our hands are tied. We've got to comply with this legislation."

FDA won't budge

As we reported, the governmental agency in charge of enforcing the ban on CFC inhalers — the FDA — has adopted a take-it-or-leave-it attitude.

"CFC inhalers damage the ozone," spokesman Christopher Kelly told us. "People will have to get used to the new (HFA) inhalers."

Kelly said his agency researched its decision to phase-out CFC inhalers for several years. He referred us to pages of documentation on the agency's Web site about the ban and the "safe and effective" alternatives for CFC inhalers.

One FDA posting said: "There are three albuterol HFA inhalers and one levalbuterol HFA inhalers that are alternatives to albuterol CFC inhalers. Each of the HFA inhalers is different. It is important to remember that it is the deep breath that gets the medication into a patient's lungs, not the force of the spray. The spray from an albuterol HFA inhaler may feel softer than the spray from an albuterol CFC inhaler, but this will not affect the amount of drug that a patient breathes into their lungs.

The posting adds: "The spray from an albuterol CFC inhaler often hits the back of the mouth. The spray from an HFA inhaler is a fine mist that may actually be easier to breathe into the lungs compared to a CFC inhaler. If patients have problems with the albuterol HFA inhaler, they should talk to their healthcare provider as a different product may work better for them."

Kelly said his agency knows many consumers are upset about the ban on CFC inhalers. More than 300 consumers, he said, filed complaints with FDA last year about this action: 295 by phone and 39 by e-mail.

"The complaints concerned the cost increase and patients getting used to the new formulation," Kelly said. "But I don't think our position is going to change on this."

He and other proponents of the HFA inhalers claim the costs "should" come down in the next few years.

Until that happens, The Partnership for Prescription Assistance (PPA) and drug companies that make HFA inhalers say special programs and money-saving coupons are available to help consumers cover the higher prices.

Whose job is it?

ConsumerAffairs.com also learned the American Lung Association has received complaints from asthma patients about the ban and the switch to HFA inhalers.

"Patients tell us the HFA inhalers are not working as well as their CFC inhalers," said Dr. Norman H. Edelman, the association's chief medical officer. "I have no idea how prevalent this is, but we know there are some people who feel this way.

"There is such a thing as post-marketing surveillance," he added. "It is the responsibility of the FDA to ask doctors to collect these reports and make a determination if there is a problem. Right now, I can't tell if it's a problem or if people feel antsy."

But according to its many fund-raising publications and its Web site, it is the job of the Lung Association to be an advocate for patients.

"The American Lung Association is the leading organization working to save lives, improve lung health and prevent lung disease. With your generous support, the American Lung Association is 'Fighting for Air' through research, education and advocacy," boasts the organization's Web site.

Edelman says patients will "notice a difference" when using HFA inhalers. "It's a softer feel. The particles are more finely disbursed and people don't feel that same blast."

Patients must also prime the HFA inhalers — and keep them clean to prevent build-up and blockage of the medication.

"But as far as we know, the studies done on these (HFA inhalers) show that when they are used properly, that are as effective as the old (CFC) inhalers," Edelman said.

As a pulmonologist, though, Edelman said his focus is making sure patients get their asthma under control.

"Someone who uses a 'quick reliever' inhaler many times a day does not have well-controlled asthma," he said. "Patients shouldn't need their quick relief inhalers more than two to three to four times a week.

"Asthma is a variable disease and doctors are always readjusting medications and dosages," he added. "If patients are not getting good asthma control, they need to talk to their doctor."

Many asthma patients, however, told us what they really need are their trusty and affordable CFC inhalers.

Brute political force

The National Campaign to Save CFC Asthma Inhalers is trying to help those patients get what it agrees is much needed medication. And the California-based organization encourages asthma and pulmonary patients to join its grassroots campaign.

"We're the only game in town and our strategy is simple: brute political force to get Congress to amend the Clear Air Act amendments of 1990," says the organization's founder, Arthur Abramson. "Congressional action is the answer."

But first, Abramson wants President Barack Obama to issue an emergency order to allow CFC inhalers in the country.

"We're the lead organization on this. If we are silent about this then there is no hope for people. We are the last hope for asthma and pulmonary patients. And we will fight this state by state."

Abramson has spent the past two years researching this issue. During that time, he says, he uncovered documents that reveal the FDA and other proponents of the ban duped consumers about the need for this action and the safety of the HFA inhalers.

The FDA, he claims, has spread such false and misleading information as:

• CFC inhalers harm the ozone. There's no evidence to support this claim, Abramson says. "The trivial amount of CFC emissions from MDIs (metered-dose albuterol inhalers) does not threaten the ozone layer," Abramson states in his group's petition to save CFC inhalers. "The amount of CFCs required for the world's pulmonary patients peaked at less than 10,000 tons (including U.S. use) per year in 1997 (less than 1% of the peak global 1987 CFC emissions for all industrial uses). U.S. CFC MDI use peaked at 2,645 tons/year in 1999. These amounts are trivial and harmless;"

• HFA inhalers are safe. "There's no way HFA inhalers are safe or effective for all patients who were doing well with CFC MDIs," Abramson told us. "They have ethanol, corn, leachables, HFA-134a Propellant, which was untested in asthma and other pulmonary patients, and many and other potentially dangerous impurities in them."

• HFA inhalers were thoroughly tested before they went on the market: The tests done of the HFA inhalers were flawed, Abramson says. "The group was too small, the duration was too short, and the population in the clinical tests was a carefully groomed group. These are not real world tests."

The organization's petition reiterates those concerns.

"The FDA's false and misleading PR campaign is primarily based on twelve week drug company bought-and-paid-for 'clinical trials' of a couple of hundred mild/moderate asthmatics each no severely ill patients are included, and black patients (who often have severe asthma), older patients (who often have complex medical problems), and COPD, cystic fibrosis and other important patient populations are frequently under-represented/not represented in these virtually worthless 'clinical trails,' which are nothing more than drug company advertising/PR sales pieces."

Abramson says he initially launched the campaign because he opposed the ban on CFC inhalers. "I've had asthma since birth -- it's not severe -- but the new HFA inhalers are not nearly as effective for me as my CFC inhaler."

Now he's fighting for pulmonary patients around the world, especially the moms who've sent him heartbreaking letters about HFA inhalers making their kids "cough until they vomit."

"Two years later, after uncovering the incredible betrayal of patients, including kids I decided to try to do something — with a small group of others — to permanently legalize CFC (inhalers) for those who are suffering terribly and who currently have no voice," he told us. "And, yes, I'm confident that we will prevail."

Back in Washington, the Asthma and Allergy Foundation of America didn't rule out the possibility of — someday — backing Abramson's effort.

"Any issue that effects patients' right, access to health care, and improves patients' quality of life might be something we'd be active in," spokeswoman Waldron told us. "If he (Abramson) gains ground on this, we might try to be involved with it in some way and try to offer our support. We advocate for patients."

Tough odds

What are the odds of getting the Clean Air Act amended?

"It would be pretty unprecedented," said Collins, the foundation's public policy and advocacy director. "The FDA has spent years on this and it has gone through the normal regulatory process.

"But," she added, "it's not outside the realm of possibility."

Until the law is changed, however, Collins said the best strategy for asthma patients to follow is to get their disease under control.

"And even if a law went into effect tomorrow (allowing CFC inhalers back on the market), that doesn't mean there will be a supply available for everyone. Those meter-dose CFC inhalers are not going to be available overnight. They are no longer available as of January 1st.

"What we're advocating patients do right now," she said, "is make the transition (to HFA inhalers) sooner than later so they can find out if they have any issues."

But the scores of patients who've contacted ConsumerAffairs.com are adamantly opposed to making that transition.

"It is completely shocking and disturbing that this (ban on CFC inhalers) is now a law considering the fact that it was millions of peoples' everyday medication for years and years," says Jamie L. of San Diego, California. "I'm 22. I've had asthma for 10 years. The HFA inhalers do not work. I am not able to breathe with them. This is horrifying. Please bring my inhalers back."

Read consumers' comments about the new inhalers.

Florida officials are trying to put a stop to one of consumers' biggest complaints — unauthorized third-party charges on local phone bills, generally known as "cramming."

Florida Attorney General Bill McCollum and Public Counsel J. R. Kelly filed a petition before the Florida Public Service Commission (PSC) seeking a prohibition against all Florida telecommunication companies placing unauthorized third-party charges on consumers telephone bills.

Such charges are usually for products or services not requested, authorized, needed or used by the consumer. The companies named in todays petition include Embarq, and Verizon, as well as BellSouth Telecommunications, Inc., which does business as AT&T Florida and AT&T Southeast.

This practice of phone companies placing unauthorized charges on telephone bills has increased dramatically in recent years and must not be allowed to continue, said McCollum. Florida consumers have a right to expect their telephone bills will not be used as a billing and collection service for every vendor selling its wares.

McCollum and Kelly asked the PSC to declare that the telephone companies do not have the right to bill customers for non-telecommunication vendor products and services.

Telecommunication companies should be concerned with serving their customers, not adding on third-party charges for profit," said Public Counsel J. R. Kelly. "Consumers should not have to pay for services they neither wanted nor authorized.

Through internet advertising and telemarketing, vendors are able to bill for their products and services by obtaining the telephone numbers of unsuspecting consumers. For example, consumers accepting free coupons and other free benefits over the internet often do not realize that, when they provide their phone number as part of the acceptance, they may be unknowingly approving the purchase of some other unwanted product or service.

Once vendors of these services have a phone number, they forward any charges to a billing aggregator, which in turn provides the charges to the consumer's local telephone companies for placement on the consumer's monthly bill. The local telephone companies and the aggregators both earn a certain percentage of the total amount of charges billed to consumer telephone bills.

Consumers frequently complain about these products and services, which include voicemail boxes and other non-essential items, but are unaware of whom to contact for resolution and reimbursement. Other consumers are often unaware of the unauthorized vendor charges because of the length and complexity of telephone bills.

From July 2007 to August 2008, Florida telecommunication companies billed approximately 387,000 Florida consumers for third-party charges totaling over $26.9 million.

Cramming is a problem basically created by Congress as part of the Telecommunications Act of 1996.

Go ahead, have that second, or even third, cup of coffee. Just don't have a cigarette while you're doing it.

A 24-year follow-up study reported in Circulation: Journal of the American Heart Association finds that Long-term coffee consumption is associated with lower stroke risk in women who don't smoke.

Researchers also say regular coffee drinking may be associated with a modest reduction in stroke risk in nonsmoking women. The research, which used Nurses' Health Study data, found that compared with women who drank less than one cup of coffee a month, the risk of all types of stroke was:

• 20 percent less in women drinking four or more cups/day.
• 19 percent less in women drinking two to three cups/day.
• 12 percent less in women drinking coffee five to seven times a week.

Previous analyses -- including a 2006 report from the Nurses' Health Study -- raise the possibility that coffee may help protect against diabetes and does not appear to raise the risk of heart attack, researchers said.

However, the few studies on stroke had contradictory findings, said Esther Lopez-Garcia, Ph.D., lead author of the study and assistant professor of preventive medicine at the Universidad Autonoma de Madrid, Spain.

Researchers from Spain and Harvard Medical School in Boston analyzed the impact of coffee consumption on stroke risk over 24 years. The subjects were 83,076 women who began the study in 1980 with no history of stroke, heart disease, diabetes or cancer.

Every two to four years, the women completed food frequency questionnaires about their diet, including their consumption of coffee, tea, decaffeinated coffee and caffeinated soft drinks. Researchers used a woman's average coffee consumption from all available reports (prior to a stroke or death) for the analysis.

Between 1980 and 2004, 2,280 strokes were documented: 1,224 ischemic, caused by blockage of a blood vessel feeding brain tissue; 426 hemorrhagic, caused when a blood vessel feeding brain tissue bursts; and 630 of undetermined type.

To assess the role of coffee consumption, the researchers adjusted for several factors known to influence stroke risk, including age, smoking status, body mass index, physical activity, alcohol intake, menopausal status, use of hormone replacement therapy, use of aspirin and diet. This type of analysis can only account for known factors but cannot consider risk predictors as yet unidentified.

Among other findings, coffee was not associated with either raised or lowered stroke risk in the subgroups of women with high blood pressure, diabetes or high cholesterol.

Researchers said women who drink a lot of coffee also tend to smoke. The difference between smokers and nonsmokers was noted:

• Among women who had never smoked or quit the habit, drinking four cups or more of coffee a day was associated with a 43 percent reduction in stroke risk.
• Among smokers, drinking four cups or more was associated with only a 3 percent reduction in risk.

"The potential benefits of coffee cannot counterbalance the detrimental effects smoking has on health," Lopez-Garcia said.

Other caffeinated beverages, such as tea and caffeinated soft drinks, as well decaffeinated coffee, were not associated with any change in stroke risk.

"This finding supports the hypothesis that components in coffee other than caffeine may be responsible for the potential beneficial effect of coffee on stroke risk," she said. "Antioxidants in coffee lower inflammation and improve blood vessel function."

While possibly good news for current coffee drinkers, the authors said their findings don't provide enough evidence to recommend that women start drinking coffee for its health benefits.

"I would also add that the beneficial effects of coffee can only be applied to healthy people," Lopez-Garcia said. "Anyone with health problems that can be worsened by coffee (insomnia, anxiety, hypertension or heart problems) should talk to their doctor about their specific risk."

Stroke is the third leading cause of death in the United States after diseases of the heart and cancer.

Texas Attorney General Greg Abbott has charged the owners of two investment plans with orchestrating a fraudulent scheme that targeted retirees and teachers.

According to the state's enforcement action, Howard G. Judah Jr. and Gregory F. Jablonski falsely guaranteed lucrative investment returns, misrepresented their "life settlement" policy investment offerings, failed to disclose material information to investors, and committed multiple violations of the Texas Securities Act.

Travis County District Judge Suzanne Covington granted the Attorney General's request for receivership and issued an order seizing more than $19 million held in several bank accounts under the defendants' control.

"At a time of extraordinary market volatility, the defendants attempted to take advantage of anxious investors by falsely promising safe investments and guaranteed returns," said Attorney General Greg Abbott. "Today's enforcement action charges the defendants with failing to make required disclosures, selling unregistered securities and other violations of the Texas Securities Act."

According to State Securities Board investigators, Judah, a three-time felon convicted of financial crimes, and Jablonski each formed a limited liability company in their respective states, both known as National Life Settlements, LLC.

Together they marketed and sold three principal investment schemes that are identified in the state's enforcement action as secured notes, the Immediate Income Investment plan and membership interests in special purpose limited liability companies. Neither the defendants' securities -- nor their salespeople -- were registered with State Securities Board, as required by law.

The secured notes program purported to offer notes -- written promises to pay sums of money -- secured by life settlement policies. In life settlements, a life insurance policy owner sells the policy to a third party for more than the cash surrender value offered by the insurance company. The purchaser then must make premium payments and receives the payout upon the insured's death.

According to the enforcement action, investors were told that their investments were guaranteed, had little or no risk, and would deliver up to a 10 percent annual return on the investment. Like the secured notes program, the Immediate Income Investment plan purported to have little or no risk. Investors were told their funds would yield a fixed rate of return and feature bi-weekly income payments.

The marketing materials claimed that National Life was "among the most secure, stable, and highest paying investment programs available today." National Life also claimed that certain products guaranteed a 10 percent rate of return, and promised that its investment opportunities were "not subject to market volatility." Both statements constitute a "fraudulent practice" under the Texas Securities Act.

Between November 2006 and December 2008, the scheme raised approximately $20 million from 240 individual investors. That amount includes more than $2.5 million from employees who withdrew assets from their pension funds to invest in the defendants' investment scheme.

Of the nearly $20 million that the defendants raised from investors, approximately $3.16 million was used to compensate National Life's unregistered securities salespeople. It is illegal to pay commissions to securities salespeople who have not registered with the State Securities Board.

Nearly $900,000 has been transferred to Judah and his family members, including $230,000 for Judah's salary. More than $650,000 was paid to Jablonski and his company, JCJ and Associates.

Despite the guaranteed annual investment returns and bi-weekly payments promised to investors, National Life has only paid investors approximately $3 million over the two-year period.

Court documents filed by the Office of the Attorney General indicate that the Internet-based advertisements and false statements also constituted Texas Securities Act violations. For example, the defendants wanted investors to think their investments were subject to regulatory oversight. Marketing materials produced by the defendants falsely stated that their products were regulated by the Texas Department of Insurance. And they furthered their attempts to project security and legitimacy by falsely claiming that National Life received over $60 billion in "commission checks" from the Federal Reserve in 2008.

According to investigators, Judah and Jablonski were poised to launch a third scheme that would sell membership interests in special purpose limited liability companies. Investors were told that their investment would yield a tax-free return on investment as high as 11 percent annually.

More Scam Alerts ...

Something was wrong.

Victoria O. knew it the moment she took the first puff of her new inhaler. A burning sensation blistered the back of her throat. It moved down to her windpipe and into her lungs.

"It felt like liquid acid," the Kissimmee, Florida, woman says. "I realized I couldn't breatheI thought I was going to die."

So did a woman thousands of miles away, who used the same type of inhaler for her asthma.

"I used to go hiking a lot, but I'm afraid to after I had a severe asthma attack while I was hiking," says 20-year-old Marissa M. of West Hills, California. "My new inhaler did not work and I was fearful of dying on a trail."

An asthma sufferer in New York experienced similar fears when she used that same type of inhaler.

"I thought I was going to die on the way to hospital," says Danielle A. of Brentwood, New York. "I had to pull over and call an ambulance. I can't rely on these new inhalers. I can't breathe with them. That's like having your throat close. It's a very real feeling that you're going to die."

These asthma sufferers are not alone.

In the past few months, ConsumerAffairs.com has heard from more than 55 people nationwide with various pulmonary conditions who are scared, outraged, and often literally gasping for breath because they can no longer use the medication that gives them instant relief: their chlorofluorocarbon (CFC) albuterol inhalers.

That's because metered-dose CFC inhalers are — as of December 31, 2008 — banned in the United States under an international agreement called the Montreal Protocol on Substances that Deplete the Ozone Layer.

According to the Food and Drug Administration (FDA) — and other supporters of this 1987 agreement — the CFC propellant in the inhalers damages the ozone.

"CFCs reduce the amount of ozone in the ozone layer that surrounds the earth and protects the earth against the sun's harmful rays," the FDA said in a written statement. "The loss of ozone can increase the risk of skin cancer, cataracts, and other health problems."

Asthma and other pulmonary patients must now use an environmentally friendly — and more expensive — type of inhaler that contains a propellant called hydroflouroalkane (HFA).

"A different feel"

The FDA says HFA inhalers have a different feel and taste — and patients need to take deep breaths when using them. But the HFA inhalers, the agency says, give the same dose of albuterol as CFC inhalers and are a "safe and effective" alternative for the more than 40 million asthma and pulmonary patients nationwide.

Those who've relied on their CFC "rescue inhalers" for years disagree.

For the past several weeks, ConsumerAffairs.com has talked to scores of asthma and pulmonary patients nationwide about what many call a "life-threatening" ban on CFC inhalers and how they're adjusting to the new generation of rescue inhalers.

Here are the patients' concerns:

• The HFA inhalers don't give them quick relief;

• In some cases, the HFA inhalers made their asthma worse. Some say they're allergic to the ethanol in the HFA inhalers;

• HFA inhalers are more expensive than CFC inhalers. The price has skyrocketed from about $5 for a CFC inhaler to around $50 for an HFA inhaler. That's because there is no generic alternative for HFA inhalers;

• Many are not convinced CFC inhalers harm the ozone. They also say they're environmentalists, but believe the government picked the wrong product to ban;

• Many wonder why people can't choose which type of inhaler to use. They understand some patients don't have problems with the HFA inhalers. But what about those who do? Why can't they use their old CFC inhalers?

A pharmacist in the Midwest isn't surprised by our findings. None of his clients are happy about the ban or their HFA inhalers, he says.

Neither are the hundreds of asthma and pulmonary patients who have contacted the National Campaign to Save CFC Asthma Inhalers. The California-based group is lobbying Congressional leaders to amend the Clean Air Act and make CFC inhalers permanently legal in the United States.

But our investigation reveals the government isn't likely to change its position on this issue.

An FDA spokesman told ConsumerAffairs.com the agency thoroughly researched this topic and stands by its decisions.

The FDA also said a generic alternative should be available in a few years, which will reduce the cost of HFA inhalers.

Until then, some pharmaceutical companies and The Partnership for Prescription Assistance have programs to help consumers cover the increased costs of HFA inhalers.

"Just as effective"

During our investigation, we also talked to The American Lung Association.

A spokesman told us the HFA inhalers now on the market — ProAir, Proventil, Ventolin, and Xopenex — are just as effective as the CFC inhalers when properly used.

But the key issue, he said, is for patients to get their asthma under control.

Asthma sufferers like Victoria in Florida say their disease was under control until they used an HFA inhaler.

"In the 30 plus years I've had asthma, I have never had it spiral out of control this quickly or this severely," Victoria says. "I think they've put poison on the market."

Victoria's health problems started last fall when she developed bronchitis. Her doctor gave her a prescription for a ProAir inhaler.

"Upon initial use I realized I was in respiratory distress," she says. "And as I administered the second treatment, I felt a burning sensation in my lungs. Thank God I have a nebulizer. I was able to clear myself that day. But within a week, I felt like I was dying. I had a high fever, couldn't breathe, and I haven't been better since."

Victoria's doctor gave her antibiotics "over and over again."

"But my health continued to decline," she says, adding her doctors suspect she had an allergic reaction to the ethanol in the HFC inhaler. "Eventually, I was up all night because of a constant choking sensation, shivering, temple headaches, nausea, throat pain, heart palpitations, general body pain, and severe asthma. My hair started to fall out. I was rushed to the emergency room twice and was in the hospital from Christmas to New Years."

The ripple effects from using a HFA inhaler, Victoria says, have damaged nearly every aspect of her life.

"This is killing me. I'm at a point where my boss is ready to fire me (because she's missed so much work). My credit score has gone down because of my medical bills. I gave up my New York apartment and asked my husband to come to Florida. He had to quit his job in New York City and came to Florida to care for me."

She adds: "My asthma was extremely controlled. But I've gone from someone with controlled asthma to someone who has to be careful where I go. I even have a handicap sticker now."

Remember Marissa in California? She says the HFA inhalers also wreaked havoc on her active lifestyle.

"There are a lot of things I can't do anymore. I was into hiking and rock climbing. But I'm terrified to do those anymore. I'm scared because my (HFA) inhaler doesn't work. I'm waiting and waiting for relief. I've had people have to carry me to my nebulizer.

"Not being able to do the things I love — and not being able to get the relief for my asthma — is sheer torture," says Marissa, who has kept her disease in control for the past 12 years. "I'm always out of breath and I have more severe asthma attacks than ever before."

Marissa, who calls herself an environmentalist, says the government chose the wrong product to pull off the market.

"It's amazing to me that you still have Hummers and NASCAR racing and yet you have to get rid of a life-saving medicine. Why ban a medicine that is saving peoples' lives? I just can't see how something like this (CFC inhaler) makes a big impact on the environment.

"I think that something that can save lives should be made available to the people who need it," she says. "HFA inhalers do not work for everyone. Take the SUV's and Hummers off the road before you take away my CFC inhaler. It is my breath and my independence."

One problem Marissa hasn't faced with the HFA inhalers is the higher cost. "I'm lucky and have very good insurance. I still pay $5. But I have friends who are not doing well in this economy and they have asked to use my inhaler."

Higher cost

Many asthma patients who contacted ConsumerAffairs.com told us they can't afford the pricier HFA inhalers.

"I called to see how much my inhaler would cost — $32 at Wal-Mart," says Mary Kathleen D. of Tamaqua, Pennsylvania. "The ProAir inhalers are half the size of the albuterol ones, which only cost $22. My husband is on workman's compensation for a knee injury and will be having a lung reduction surgery soon. I can't afford $32 for one inhaler that I need."

Heather of West Virginia can't, either.

"They're too expensive," she says of the HFA inhalers. "I have two kids to take care ofand there is a big difference between paying $20 and paying $50 for an inhaler."

During our investigation, we learned some consumers stocked up on CFC inhalers before the ban went into effect in December.

"I went to Target and paid out of pocket for four CFC inhalers and then went on some India company's Web site and had four more shipped to me," says Dean D. of Boca Raton, Florida. "So I have my stash or I couldn't continue to work out as aggressively as I do.

"My asthma is exercise-induced," he adds. "I went for a run and I couldn't breathe (with the HFA inhalers.). In fact, it made my breathing worse. The feeling is like always needing to yawn and not getting a complete and satisfying amount of air in my lungs. It's very scary. I was afraid to push and complete the workout."

Dean says his stash of eight CFC inhalers should last him about a year and a half.

"After that, I guess I will try the HFA inhalers again. Maybe there will be a new product on the market. Or I may look at India, China, or Canada. What else can I do? Stop working out? "

Another worried consumer stocked up on CFC inhalers because she couldn't breathe with the HFA-propelled ones.

"I paid hundreds of dollars out of pocket and got 37 (CFC) inhalers," says Danielle A. of Brentwood, New York. "Those should last me about two years. Even an expired albuterol (CFC) inhaler is more effective than the ProAir."

Danielle doesn't want to think about what will happen when her CFC inhalers are gone. It's too frightening for this 29-year-old, who says she's kept her asthma in check since she was four.

"I'm ready to burst into tears knowing that I may die sooner than later from an asthma attack because a medication that works better than any other (my CFC inhaler) is being discontinued. I'm going to keep my fingers crossed that something changes or rely on my nebulizer more. I can't rely on these new inhalers. They simply don't work. Whatever the thrust isthat's the part that's missing. The medicine doesn't reach my lungs."

A pulmonary patient in North Carolina is also fearful — and angry — about facing the future without his CFC inhalers.

"I'm outraged," says Paul E. of Pilot Mountain. "I'm fighting a cold as we speak. I have COPD and asthma and I go through one of these new inhalers in half a day. They don't work. They're about 15 percent as effective as the CFC inhalers. I don't think I'm getting as much medicine. If I am, it's not in a form that gets in my lungs. I'm seriously concerned for my health."

The ban on CFC inhalers may force Paul to give up his favorite pastime — spending time at the ball park with his kids.

"I don't think I can coach baseball anymore," he says, adding his CFC inhaler has given him instant relief for the past 20 years. "I may be doing batting practice with the kids and need my rescue inhaler.

"I've had asthma attacks where if I didn't have my (CFC) inhaler I wouldn't be here. If I have to rely on this red (HFA) inhaler I'm in bad shape."

Paul's new game plan is to order CFC inhalers online — from other countries.

"I also travel overseas in my work, so every time I go, I will bring another suitcase that I can fill full of CFC inhalers."

Hundreds of miles away in Missouri, pharmacist Pete Spalitto is hearing similar concerns about the ban on CFC inhalers.

"My customers are not happy," says Spalitto, owner of Spalitto Pharmacy in Kansas City. "I don't anyone who is happy with these (HFA inhalers). They just flat out don't want them — young, old, middle-age. Moms don't like them for their kids. Our customers can't stand them."

He adds: "The albuterol (CFC) inhalers immediately opened up the lungs for people who had asthma, emphysema, and bronchitis. When you're gasping for air, you like to feel that inhalation going in. But people don't feel that with this new (HFA) inhaler."

What's Spalitto telling his worried and upset customers?

"We try to be sympathetic and tell them they're not alone. We also tell them we can't purchase the albuterol inhalers anymore — these are the alternatives. If they don't work, we suggest they contact their doctor or get albuterol through a breathing machine."

The National Campaign to Save CFC Asthma Inhalers has another suggestion for asthma and pulmonary patients who are upset about the ban: join its grassroots campaign.

"We're the only game in town and our strategy is simple: brute political force to get Congress to amend the Clear Air Act amendments of 1990," says the organization's founder, Arthur Abramson. "Congressional action is the answer."

Presidential action

But first, Abramson wants President Barack Obama to issue an emergency order to allow CFC inhalers in the country.

"We're the lead organization on this. If we are silent about this then there is no hope for people. We are the last hope for asthma and pulmonary patients. And we will fight this state by state."

Abramson has spent the past two years researching this issue. During that time, he says, he uncovered documents that reveal the FDA and other proponents of the ban duped consumers about the need for this action and the safety of the HFA inhalers.

The FDA, he claims, has spread such false and misleading information as:

• CFC inhalers harm the ozone: There's no evidence to support this claim, Abramson says. "The trivial amount of CFC emissions from MDIs (metered-dose albuterol inhalers) does not threaten the ozone layer," Abramson states in his group's petition to save CFC inhalers. "The amount of CFCs required for the world's pulmonary patients peaked at less than 10,000 tons (including U.S. use) per year in 1997 (less than 1% of the peak global 1987 CFC emissions for all industrial uses). U.S. CFC MDI use peaked at 2,645 tons/year in 1999. These amounts are trivial and harmless;"

• HFA inhalers are safe: "There's no way HFA inhalers are safe or effective for all patients who were doing well with CFC MDIs," he said. "They have ethanol, corn, leachables, HFA-134a Propellant, which was untested in asthma and other pulmonary patients, and many and other potentially dangerous impurities in them;"

• HFA inhalers were thoroughly tested before they went on the market: The tests done of the HFA inhalers were flawed, Abramson says. "The group was too small, the duration was too short, and the population in the clinical tests was a carefully groomed group. These are not real-world tests."

The organization's petition reiterates those concerns.

"The FDA's false and misleading PR campaign is primarily based on twelve week drug company bought-and-paid-for 'clinical trials' of a couple of hundred mild/moderate asthmatics each — no severely ill patients are included, and black patients (who often have severe asthma), older patients (who often have complex medical problems), and COPD, cystic fibrosis and other important patient populations are frequently under-represented/not represented in these virtually worthless 'clinical trails,' which are nothing more than drug company advertising/PR sales pieces."

Abramson says he initially launched this campaign because he opposed the ban on CFC inhalers. "I've had asthma since birth — it's not severe — but the new HFA inhalers are not nearly as effective for me as my CFC inhaler."

Now he's fighting for pulmonary patients around the world, especially the moms who've sent him heartbreaking letters about HFA inhalers making their kids "cough until they vomit."

"Two years later, after uncovering the incredible betrayal of patients, including kidsI decided to try to do something — with a small group of others — to permanently legalize CFC (inhalers) for those who are suffering terribly and who currently have no voice," he told us. "And, yes, I'm confident that we will prevail."

FDA won't budge

The FDA, however, isn't likely to change its position on the ban.

Why?

"CFC inhalers damage the ozone," spokesman Christopher Kelly told us. "People will have to get used to the new (HFA) inhalers."

Kelly said his agency researched its decision to phase-out CFC inhalers for several years.

He referred us to pages of documentation on the agency's Web site about the ban and the "safe and effective" alternatives for CFC inhalers.

One FDA posting said: "There are three albuterol HFA inhalers and one levalbuterol HFA inhaler that are alternatives to albuterol CFC inhalers. Each of the HFA inhalers is different. It is important to remember that it is the deep breath that gets the medication into a patient's lungs, not the force of the spray. The spray from an albuterol HFA inhaler may feel softer than the spray from an albuterol CFC inhaler, but this will not affect the amount of drug that a patient breathes into their lungs."

The posting adds: "The spray from an albuterol CFC inhaler often hits the back of the mouth. The spray from an HFA inhaler is a fine mist that may actually be easier to breathe into the lungs compared to a CFC inhaler. If patients have problems with the albuterol HFA inhaler, they should talk to their healthcare provider as a different product may work better for them."

Kelly said his agency knows many consumers are upset about the ban on CFC inhalers.

More than 300 consumers, he said, filed complaints with FDA last year about this action — 295 by phone and 39 by e-mail. "The complaints concerned the cost increase and patients getting used to the new formulation," Kelly said. "But I don't think our position is going to change on this."

When asked about buying CFC inhalers from countries oversea, Kelly said: "Buying the CFC albuterol from other countries, outside the closed U.S. supply system, (either prior to or after 12/31/08) is not legal and the safety and efficacy of the product is unknown."

Kelly and other proponents of the HFA inhalers say the costs should come down in the next few years.

In the meantime, The Partnership for Prescription Assistance (PPA) and drug companies that make HFA inhalers say special programs and money-saving coupons are available to help consumers cover the higher prices.

Another organization that's hearing complaints about the ban on CFC inhalers is The American Lung Association.

"Patients tell us the HFA inhalers are not working as well as their CFC inhalers," said Dr. Norman H. Edelman, the association's chief medical officer. "I have no idea how prevalent this is, but we know there are some people who feel this way.

"There is such a thing as post-marketing surveillance," he added. "It is the responsibility of the FDA to ask doctors to collect these reports and make a determination if there is a problem. Right now, I can't tell if it's a problem or if people feel antsy."

Patients, he said, will notice a difference when using HFA inhalers. "It's a softer feel. The particles are more finely disbursed and people don't feel that same blast."

Patients must also prime the HFA inhalers — and keep them clean to prevent build-up and blockage of the medication.

"But as far as we know, the studies done on these (HFA inhalers) show that when they are used properly, that are as effective as the old (CFC) inhalers," Edelman said.

As a pulmonologist, though, Edelman's focus is making sure patients get their asthma under control.

"Someone who uses a 'quick reliever' inhaler many times a day does not have well-controlled asthma," he said. "Patients shouldn't need their quick relief inhalers more than two to three to four times a week. Asthma is a variable disease and doctors are always readjusting medications and dosages," he added. "If patients are not getting good asthma control, they need to talk to their doctor."

Back in Florida, Victoria's doctors are still trying to find out why her asthma suddenly spun out of control. The key suspect, she says, is her HFA inhaler.

"I've seen a pulmonologist, who is pretty much boggled about how someone can go from no asthma to severe in a couple months. And my immunologist is trying to figure out if I had a really bad (allergic) reaction and that's why my hair is falling out. I also have to see a cardiologist because of the choking sensations at night."

Victoria — who still receives nebulizer treatments every four to six hours — doesn't want other asthma patients to experience similar problems with an HFA inhaler.

Neither do the scores of other asthma-sufferers who've contacted ConsumerAffairs.com.

The only solution, they say, is to bring back CFA inhalers. And let patients decide which type of inhaler works best for them.

"Obviously, the HFA inhalers work for some people," says Ivy G. of Van Nuys, California. "But for those of us that they don't work for, give us the option of having our old (CFC) inhalers. No one has a problem if they (HFA inhalers) work, but they don't work for everyone. They don't work for me. I can't breathe when I use them."

Victoria agrees.

"I cannot believe the FDA has allowed these HFA Inhalers to be forced upon an unsuspecting public. They've put a dangerous drug on the market that is causing people to suffer. The FDA has to reconsider this ban."

Read consumers' comments about the new inhalers.

February 16, 2009
The Federal Reserve last year adopted new credit card rules that ban practices often cited as unfair to consumers, such as raising the interest rate on an existing credit card balance when the consumer is paying the credit card bill on time.

However, those rules don't go into effect until mid-2010, prompting Sen. Chris Dodd (D-CT), chairman of the Senate Committee on Banking, Housing and Urban Affairs to re-introduce the Credit Card Accountability, Responsibility and Disclosure Act. The measure was offered last week.

Tamara Draut, Vice President for Policy and Programs at Demos, which calls itself a non-partisan policy center, supports legislative measures to re-regulate the credit card industry and bolster the household economy.

"America's families are facing a dire economy, and this bill couldn't come at a better time," Draut said. "As the consequences of the subprime meltdown spread, banks are openly increasing interest rates and fees on their credit card customers in order to cover losses in other areas. The only reason this is possible is because in the absence of almost any regulation, issuers have tilted the playing field heavily in their favor."

Draut said the bill would level the playing field between borrower and lender by putting an end to some of the most arbitrary, abusive, and unfair credit card lending practices that trap consumers — particularly disadvantaged and minority borrowers-in an unending cycle of costly debt. The bill would:

• Protect consumers from "any time, any reason" interest rate increases and account changes;

• Prohibit unfair application of card payments;

• Protect cardholders who pay on time;

• Limit fees and penalties;

• Ensure that cardholders are informed of the terms of their account; and

• Protect young consumers from credit card solicitations.

"Demos research shows that inequitable credit card underwriting practices have shifted the cost of credit to individuals least able to afford it, while at the same time generating some of the highest profits in the entire banking sector," Draut said. "Low-income families and households of color, primarily African Americans and Latinos, bear the brunt of the cost of credit card deregulation through excessive fees and high interest rates."

Last fall, a similar measure known as H.R. 5244 in the 110th Congress, passed the House of Representatives in September 2008 with largely bipartisan support. The Senate, however, did not take up the bill before the session ended.

Although the Federal Reserve and other bank regulators issued a rule in December 2008 that would prohibit many of the same unfair practices, Draut notes the rule does not take effect until July 2010, giving credit card companies 18 months to proceed unchecked and delaying relief for millions of American consumers.

The peanut butter salmonella outbreak has already had wide-ranging and, in some cases devastating, consequences. It is likely only a matter of time before a class-action lawsuit is filed against the Peanut Corporation of America (PCA), the company whose contaminated peanuts are believed to be the source of the outbreak.

Indeed, several firms are already laying the groundwork for a possible suit, gathering data and asking consumers who have been affected to contact their offices.

As the Pennsylvania firm of Pogust, Braslow & Millrood notes on its website, the FDA has already blamed PCA for failure to manufacture foods under conditions and controls necessary to minimize the potential for growth of microorganisms and contamination. The law firm of Parker Waichman Alonso is offering free consultations to those affected by the outbreak.

But while some aspects of the incident make a class action seem appealing, any suit will invariably face tough hurdles before it moves forward.

Smoking guns

At this point, there is little doubt as to PCAs liability for the outbreak, which has so far caused nine deaths and around 600 illnesses. The bacteria are thought to have originated from PCAs Georgia plant, and the evidence against the company is staggering. The FDA announced that PCA knowingly shipped contaminated peanut butter 12 times in the past two years.

Last Wednesday, PCA president Stuart Parnell refused to testify at Congressional hearings, eventually causing frustrated lawmakers to dismiss him from the session altogether. In mid-January, PCA issued a voluntary recall of certain products manufactured after July 1, 2008; Parnell insisted the recall was instituted with the safety of our consumers as our first priority.

In the weeks that followed, more products were added to the recall list, and on February 12, in a stunning development, Texas health officials ordered PCA to recall all products ever produced at a second plant, located in Plainview, Texas. The states report detailed rodent droppings, bird feathers, and dead rodents in a crawl space above the area where the peanut butter was manufactured. Further, officials found that the air flow system was pulling the debris into the processing area, posing enormous health risks.

Finally, PCA has a history of health-related allegations; it settled a lawsuit in 1992 after inspectors discovered toxic mold in their products, and in 2001 health officials found that PCA peanuts may have been exposed to pesticides.

Litigation difficult

Even with such seemingly unassailable evidence, any class action brought against the company will be difficult to litigate. In February 2007, a class action was filed on behalf of individuals who fell ill due to a salmonella outbreak affecting peanut butter manufactured by ConAgra. The suit, brought by lead plaintiffs James Daniels and Linda Oswald, was handled by Marler Clark, a firm that has for 15 years specialized in food contamination and resulting illnesses.

In spite of the number of potential class members who stepped forward — 2,200 families contacted Marler Clark — and the attorneys extensive experience in the field, in August 2008 a federal judge in Georgia refused to let the suit proceed. In his order, Judge Thomas Thrash said that, whether or not the class action was certified, each class member would have to prove individual issues such as injury, causation, and damages.

Essentially, the judge said, the suit would proceed in the same manner regardless of whether it was certified as a class — each class member would need a separate trial — negating the judicial efficiency that is usually achieved through class actions.

The judge also said that the variation in state laws would render the suit impossible to litigate, insisting that class certification is impossible where the fifty states truly establish a large number of different legal standards governing a particular claim. The judge went so far as to suggest that litigation might not even be the best way to resolve the controversy; in that case, class members were entitled to a full refund from ConAgra, which Judge Thrash said might be the best resolution for all parties involved.

While no two cases are identical, any class action brought against PCA will likely face similar factual and legal hurdles.

Individual suits

In any event, whatever form it takes, there will be plenty of litigation; there have already been at least a dozen individual suits filed against PCA. The Minnesota law firm of Pritzker Olsen has filed a wrongful death suit on behalf of a 72-year-old woman who died after eating King Nut peanut butter, which is manufactured by PCA.

Marler, the attorney who brought the class action against ConAgra, has already filed a number of individual lawsuits, including one on behalf of two children who were hospitalized after eating Kelloggs peanut crackers containing PCA-manufactured peanuts. He is looking into at least two suits on behalf of families who lost loved ones to the contaminated products.

Marler says that the scope of illness is startling, even given his long background in the field. He went so far as to speculate that the scope of the product recall may eventually prove to be the largest recall of food weve ever had in this country.

PCAs insurance company, anticipating the coming wave of litigation, isnt taking any chances either. On February 3, Hartford Casualty Insurance filed suit against PCA, seeking a declaratory judgment that the companys policy excludes claims for salmonella infection.

In any case, it looks like PCA likely wont survive the scandal; the company filed for Chapter 7 bankruptcy on Friday. Undeterred, Marler says that if PCA doesnt have enough assets and insurance to cover civil settlements, companies who used the peanuts in their products will have to step up and cover the costs.

Major brands OK

None of PCA's products were sold directly to consumers. They were distributed to long-term care facilities, universities, food service industries, and private label food companies in the United States, Canada, Haiti, Korea, and Trinidad.

U.S. food makers, however, used the company's peanut butter and paste to make various products, including cookies, crackers, ice cream, energy bars, and dog treats. That's why so many food manufacturers have recently recalled their products.

And the list of products pulled off store shelves continues to grow almost daily, making it one of the country's largest food-related recalls.

The massive recall, however, does not include any of the major brands of peanut butter sold on grocery stores shelves. That's a message the makers of Jif, Skippy, and Peanut Pan peanut butters have taken great pains to broadcast to consumers. Some have taken out ads in newspapers nationwide to reassure buyers their products are safe to eat.

The FDA now has a complete list of all products recalled in the salmonella outbreak on its Web site. Consumers can check that Web site daily to see if their favorite products are included in any recalls.

Salmonella is an organism that can cause serious and sometimes fatal infections in young children, frail or elderly people, and those with weakened immune systems. Symptoms include fever, diarrhea (which may be bloody), nausea, vomiting, and abdominal pain. In rare cases, it can cause more severe illnesses, including arterial infections (i.e., infected aneurysms), endocarditis, and arthritis.

Health officials say salmonella can also be transferred to humans who handle pet treats tainted with the organism. They advise pet owners to wash their hands after they come touch these pet treats.

Symptoms of salmonella infection in pets include lethargy, diarrhea, bloody diarrhea, fever, and vomiting. Some pets, however, may have a decreased appetite, fever and abdominal pain.

There's more bad news for the peanut processing company linked to the nationwide salmonella outbreak, which has sickened more than 600 people nationwide and may have caused the deaths of nine others.

Peanut Corporation of America (PCA) on Friday filed for Chapter 7 bankruptcy in Virginia, according to the Associated Press.

The action comes just days after PCA's president, Stewart Parnell, refused to answer questions from members of the House Energy and Commerce investigations subcommittee.

That subcommittee is looking for ways to prevent another outbreak like this one, which has forced food manufacturers to recall more 2,000 products that contain peanut butter or paste made at PCA's Blakely, Georgia, plant.

The bankruptcy action also comes on the heels of Thursday's order by the Texas Department of State Health Services to recall all products PCA ever shipped from its plant in Plainview, Texas.

During a recent inspection of that plant, inspectors discovered dead rodents, bird feathers, and rodent excrement in a crawl space above the production area. Plainview is the second PCA plant where inspectors have found unsanitary conditions.

In January, inspectors with the Food and Drug Administration (FDA) discovered roaches, mold, and a leaking roof at the company's Georgia plant.

Inspectors also uncovered documents that revealed PCA shipped peanut products that had tested positive for salmonella, including the strain linked to the current outbreak: Salmonella Typhimurium.

That discovery also exposed a dirty secret in the food manufacturing industry: companies are not required to disclose internal tests to the FDA or state officials.

PCA is now the focus of a criminal investigation for allegedly shipping tainted products. It also faces more than a dozen civil lawsuits.

Damaging evidence has already surfaced in the investigation, including e-mails that indicate Parnell ordered products he knew were tainted with salmonella to be shipped anyway.

Some of those potentially-tainted products made their way to poor school children of victims of recent disasters.

Legal experts say companies file for Chapter 7 bankruptcy protection to liquidate their assets and distribute the proceeds to creditors.

PCA's bankruptcy filing reveals the company's debt and assets both ranged between $1 million and $10 million, according to the Associated Press. The filing also states the recalls have been "extremely devastating" to PCA's financial condition.

Lawyers handling some of the recent litigation against PCA told the Associated Press they are optimistic that victims and their families can still be compensated.

While the bankruptcy proceeding could postpone litigation against the company, the lawyers said they will push a judge to allow the civil actions to proceed.

Many lawyers have also filed lawsuits against King Nut Co. and Kellogg Co., which used PCA-tainted ingredients in their products.

"Even if Peanut Corp. doesn't have enough insurance and enough assets to cover the damages, King Nut and Kellogg will have to step up," attorney Bill Marler told the Associated Press. He has filed seven lawsuits against PCA on behalf of more than 40 possible victims.

None of PCA's products were sold directly to consumers. They were distributed to long-term care facilities, universities, food service industries, and private label food companies in the United States, Canada, Haiti, Korea, and Trinidad.

U.S. food makers, however, used the company's peanut butter and paste to make various products, including cookies, crackers, ice cream, energy bars, and dog treats. That's why so many food manufacturers have recently recalled their products.

And the list of products pulled off store shelves continues to grow almost daily, making it one of the country's largest food-related recalls.

The massive recall, however, does not include any of the major brands of peanut butter sold on grocery stores shelves. That's a message the makers of Jif, Skippy, and Peanut Pan peanut butters have taken great pains to broadcast to consumers. Some have taken out ads in newspapers nationwide to reassure buyers their products are safe to eat.

The FDA now has a complete list of all products recalled in the salmonella outbreak on its Web site. Consumers can check that Web site daily to see if their favorite products are included in any recalls.

Salmonella is an organism that can cause serious and sometimes fatal infections in young children, frail or elderly people, and those with weakened immune systems. Symptoms include fever, diarrhea (which may be bloody), nausea, vomiting, and abdominal pain. In rare cases, it can cause more severe illnesses, including arterial infections (i.e., infected aneurysms), endocarditis, and arthritis.

Health officials say salmonella can also be transferred to humans who handle pet treats tainted with the organism. They advise pet owners to wash their hands after they come touch these pet treats.

Symptoms of salmonella infection in pets include lethargy, diarrhea, bloody diarrhea, fever, and vomiting. Some pets, however, may have a decreased appetite, fever and abdominal pain.

This blatant and costly scam holds out hope to homeowners that their property taxes will be reduced if they pay hundreds of dollars to a middleman to have their property re-evaluated, Brown said. In point of fact, homeowners can seek relief directly from their county assessor free of charge. Homeowners should be on high alert.

Companies are sending deceptive mailers to homeowners offering help in reducing property tax assessments, if the homeowner pays the company hundreds of dollars in fees.

The companies use official-sounding names such as Tax Adjusters, Tax Readjustment or Tax Review to make victims believe the company is a government agency.

Property tax reassessment is a free service provided by county tax assessors. If homeowners believe their property value has declined and they are paying too much in property taxes, the local tax assessor will review the property value for free for a possible downward assessment.

To avoid becoming a victim, homeowners should:

• Never pay money for something they did not ask for.

• Avoid a middleman; they should contact their local tax assessors office for property value reassessment.

More Scam Alerts ...

Florida Attorney General Bill McCollum has sued a company that for alleged deceptive marketing of gasoline redemption vouchers.

Tidewater Marketing Global Consultants, Inc., a Florida corporation located in Pinellas, and the companys president, Crystal Clark, are named in the lawsuit.

An investigation revealed Clark and her company engaged in an unfair and deceptive marketing scheme by producing and distributing vouchers for gasoline through a nationwide network of independent distributors, but failing to provide the gas cards as promised, McCollum said.

The vouchers were sold by distributors to retail merchants which in turn offered the vouchers to encourage sales of retail products and services. The lawsuit states hundreds of thousands of these vouchers may have been provided to consumers across the country.

Consumers with vouchers were required to register with Tidewater Marketing through websites, such as freegasredemption.com and FreeBeeGas.com, or by mail and pay a $5 fee for registration. Registered consumers were allegedly entitled to receive gift cards from Tidewater upon submitting receipts for gasoline purchases that complied with the requirements of the program.

The Attorney Generals Office is aware of over 500 complaints from consumers who never received the gift cards and is aware of at least 1,300 additional complaints reported to the Better Business Bureau and other authorities.

The lawsuit was filed under Floridas Deceptive and Unfair Trade Practices Act. Civil penalties against the company and Clark could include an injunction prohibiting them from engaging in this conduct, a requirement for consumer restitution, a $10,000 civil fine for each violation, and payment of attorneys fees and costs.

Consumers with complaints about this company should call the Attorney Generals fraud hotline at 1-866-966-7226 or may file a complaint online at http://myfloridalegal.com.

Two separate law firms are gathering information for potential class action lawsuits against Canidae and Nutro, the pet food manufacturers whose products are alleged to have caused widespread pet illness.

Progressive Law Group, LLC, is currently gathering information from pet owners who say their dogs became sick as a result of eating Canidae products, or who have information that would be useful to the suit.

According to its website, the firm focuses mainly on environmental, energy, and consumer affairs issues. More information about the Canidae suit can be found online.

Meanwhile, the Alabama firm of McCallum, Hoaglund, Cook, and Irby is gathering information for a potential class action lawsuit against the company that manufactures Nutro.

In spite of widespread complaints of pet illness, Canidae has yet to issue a voluntary recall of its foods. Last year, the company issued a statement explaining that it had changed the foods formulation and that pets needed to be transitioned gradually from the old to the new formula.

Specifically, the company cited the new foods increased levels of meat protein and the increased overall complex carbohydrate quality.

However, angry consumers said Canidae was at best inconsistent in warning pet owners beforehand of the need for the gradual formula transition. Many claimed that neither the food nor the shelves on which it was stocked provided any warning that the formula had changed.

Some consumers have speculated that the new formula, which contains carbohydrates such as corn and barley, came as a shock to their dogs systems, which had become accustomed to the old formulas more rice-centered composition. In September 2007, a lab report allegedly showed that a Canidae sample contained the painkiller acetaminophen, a charge which Canidae vehemently denied.

Menu Foods

Menu Foods, another large pet food manufacturer, was forced to issue a series of recalls in 2007, after scores of dogs became sick, some experiencing kidney failure. At least 10 deaths were reported. The Pet Food Products Safety Alliance (PFPSA) tested a batch of Nutro pet food in August 2008, and found alarming levels of copper and zinc.

Indeed, PFPSA noted that the copper levels were two to three times higher than recommended by the Association of American Feed Control Officials (AAFCO).

A multi-district class action lawsuit against Menu Foods recently settled for $24 million. The suit was brought on behalf of certain U.S. and Canadian residents who purchased recalled pet food after March 16, 2007.

Under the settlement, all class members are eligible to collect up to 100% of economic damages they suffered, as long as they can provide documentation. An explanation of the settlement and relevant court documents can be found at www.petfoodsettlement.com.

More about pets ...

February 12, 2009
You've probably received junk mail warning you that your car's warranty is about to expire, but offering an extended warranty for a reasonable price. In North Carolina, senior citizens have received calls from telemarketers pushing these bogus plans, despite being on the Do Not Call list.

"Calling people on the Do Not Call list and trying to trick them is no way to do business," said North Carolina Attorney General Roy Cooper said. "We're taking action to stop the calls and try to win money back for consumers."

At Cooper's request, a Superior Court Judge entered a temporary restraining order against Automotive Protection of New Jersey and its manager Christopher Doyle. The order requires the defendants to stop illegally telemarketing North Carolinians and to quit taking their money.

Cooper contends that Automotive Protection targeted consumers aged 65 or older, called people who had signed up for the Do Not Call Registry to stop telemarketing calls, and misrepresented the terms of its auto warranties. He is asking the court to permanently stop the company's illegal telemarketing calls and deceptive sales practices, and to order the company to pay consumer refunds and civil penalties.

A total of 24 consumers complained to the Attorney General's Consumer Protection Division about the company's illegal calls, tricky sales tactics and refusal to pay refunds. Consumers' stories, filled as affidavits with Cooper's complaint, illustrate how the company has operated in North Carolina:

• A Guilford County resident was promised that a $1,599 extended warranty would cover his car bumperto-bumper for four years. But when he got the contract, the warranty wasn't as good as the telemarketer had claimed. He called to cancel and was told he would get his $350 deposit back. Instead of returning his money, Automotive Protection charged $1,249 to his credit card.

• A 74-year-old woman in Avery County agreed to buy a warranty for her Toyota for $2,050. She made a down payment of $200 but had second thoughts within the hour and tried to cancel. She repeatedly faxed in her cancellation form and was promised her money back, but Automotive Protection kept her $200 and the company's payment processor took an additional $154.13 from her bank account.

• An 82-year-old resident of Pitt County was told that he had 30 days to review the car warranty contract before he'd be charged. But a few days later, he discovered that Automotive Protection had withdrawn $250 from his bank account using a fake check number. He wrote and called to cancel the contract but Automotive Protection's payment processor continued to try to bill him.

"Tough times bring out the scammers," Cooper said.

More Scam Alerts ...

February 12, 2009
It's perfectly fine to have your heart stolen on Valentine's Day, but not your money or your identity. That's why you should be on the lookout for fraudulent e-cards disguised as Valentines.

Indiana Attorney General Greg Zoeller says these fraudulent Valentine's Day greetings in your e-mail inbox could potentially cause major damage to computers.

Scammers have created fake e-mail notifications stating a "friend" or "family member" has sent an e-card, causing the recipient to click on a link provided. Upon clicking the link, the recipient may be taken to a malicious Web site.

"Legitimate e-card notifications will always identify the sender by name or e-mail address, never by a generic term," warned Zoeller. "Unless you recognize the full name of the sender or the e-mail address, do not open the e-card because it is likely the e-mail is fraudulent and could cause harm to your computer."

Additional tips for avoiding becoming an internet fraud victim:

• Do not respond to spam e-mails.

• Do not click on links contained within a spam e-mail, instead log on to the official Web site.

• Only open attachments from known senders.

• Do not disclose personal information in e-mail forms.

• Always compare the link in the e-mail to the link that you are actually directed to.

If you suspect a fraudulent e-mail, contact the actual business that supposedly sent the e-mail to verify if the email is genuine.

More Scam Alerts ...

Struggling satellite broadcaster Sirius XM may be on the verge of bankruptcy. The New York Timesreports the company is meeting with restructuring advisers in advance of a bankruptcy filing.

The bankruptcy would come just months after the two satellite radio broadcasters, Sirius and XM Radio, merged. At the time, both companies were in shaky financial condition a problem made worse by the recession.

Besides the general economic downturn, Sirius XM has been hurt by the disastrous slump in new car sales. The company gets most of its new customers from the sale of new cars equipped with stereo receivers.

The U.S. Justice Department approved the merger last year, despite strong opposition from some consumer groups. The Consumer Federation of America, Consumers Union and Free Press urged the Federal Communications Commission to reject the proposed XM-Sirius merger on the grounds that it would lead to higher prices.

This week Sirius XM notified subscribers that free online access would soon end, but offered to provide continued online access at no charge if customers would extend their contracts.

The combined company offers dozens of non-commercial music channels, as well as a number of commercially-supported news and talk channels.

While the Chevrolet Silverado 1500, Dodge Ram 1500, and Nissan Titan are billed as workhorses, tests by the Insurance Institute for Highway Safety show that the side crash protection these 2009 model large pickups provide is wimpy, at best.

The trio earns either poor or marginal ratings in the IIHS side tests and, even with side airbags, occupant protection in these crew-cab pickups is no better than marginal.

"The size, weight, and height of these large pickups should help them ace the side tests just like the other large pickups we've tested. Not these three," said Institute senior vice president David Zuby. "They perform worse than many cars we've evaluated."

The Dodge Ram with standard side airbags earns a marginal rating. The Nissan Titan and Chevrolet Silverado earn poor ratings when tested without their optional side airbags.

The Titan's side rating improves to marginal in models tested with side airbags, while the Silverado's optional side airbags don't improve the rating over models without them. The Silverado's ratings also apply to its twin, the GMC Sierra 1500, both of which were redesigned in 2007, so the ratings apply to 2007-09 models.

The Ram is a new design for the 2009 model year. The Titan was introduced in the 2004 model year, so results apply to 2004-09 models.

The Institute's side tests assess occupant protection in vehicles struck in the side by SUVs or pickups. Results can be compared across vehicle type and weight categories, while frontal crash test ratings can't.

This is because the kinetic energy involved in the side test depends on the weight and speed of the moving barrier, which are the same in every test. In contrast, the kinetic energy involved in the frontal crash test against an immovable barrier depends on the test vehicle's speed and weight.

The Ram, Titan, and Silverado should have an advantage in side crash tests over smaller vehicles, not just because of their size and weight but also because the dummies' higher seating positions put their heads and shoulders above the striking barrier.

Occupants of cars, for instance, are more vulnerable because their bodies are in line with the fronts of vehicles, especially tall ones, which might hit them in the side.

"These large pickups don't have to work as hard as smaller vehicles do to protect their occupants. Even with their characteristic advantages, the Ram, Titan, and Silverado still miss the mark when it comes to occupant protection in side crashes," Zuby said.

Without side torso airbags, occupants are vulnerable. What's behind the lackluster performance?

In the Silverado's case, it's a combination of a poor side structure plus the lack of side torso airbags. The truck's optional side curtain airbags are designed to protect occupants' heads, and these worked well. But occupants' upper bodies remain unprotected even with the optional side curtains.

"In the Silverado tests, there was a lot of intrusion into the occupant compartment. With no torso airbags to protect the driver and rear passenger, measures recorded on the test dummies showed that rib fractures and internal organ injuries would be likely in a real-world crash of similar severity," Zuby said. "Chevy needs to improve the Silverado's side structure, as well as add padding or torso airbags to better protect its occupants."

In contrast, the Ram and Titan's side structures are designed to better limit intrusion. The Ram's side structure/safety cage earns a good rating, while the Titan's earns acceptable marks. The Ram has standard head-protecting side curtain airbags but not torso airbags.

Both curtain and side torso bags are optional in the Titan. Adding torso airbags might improve the Ram's side protection. The Titan could be improved with some combination of structural, airbag, or door trim modifications.

"It's certainly possible to design a large pickup that offers good occupant protection in side crashes," Zuby says. Three previously evaluated 2009 models are Institute Top Safety Pick award winners. The Honda Ridgeline, Ford F-150, and Toyota Tundra all have standard side airbags with torso and head protection and good-rated structures.

The Ram would be a Top Safety Pick contender if its side rating improves to good, Zuby notes. Dodge improved the seat/head restraints in the 2009 model to earn a good rating for protection in rear crashes, while the 2006-08 models earned a poor rating.

Electronic stability control, another criterion to earn the award, also is standard.