Saturday, May 10, 2008


Joe Zealberg, a psychiatrist in Charleston, S.C., prescribed generic drugs to patients for years and rarely had problems -- until last year. A number of patients who had done very well on brand-name medications "crashed and burned" when they switched to generics, he says.

One woman "went from being perfectly fine to crying inconsolably 24 hours a day" after she switched from one generic antidepressant to another, Dr. Zealberg says. Another patient was sold a generic version of his attention-deficit drug that contained no identifying markings whatsoever -- a violation of federal rules.

Ten of his patients switched to a new generic version of the antidepressant Wellbutrin, but eight of them changed back, saying they felt anxious or shaky or their depression had returned. Several complained that the generic drug had a bad smell, he says.

Generic medications have been a boon to consumers around the world, allowing millions to buy lifesaving drugs for pennies a day.
Some 65% of all prescriptions dispensed in the U.S. are for generics, though they account for only 20% of the dollars spent, according to the Generic Pharmaceutical Association.

While there is no hard evidence of growing problems from generics, consumers and physicians are increasingly concerned as cost pressures push more patients away from brand-name drugs. At the same time, the globalization of pharmaceutical manufacturing has revealed regulatory lapses.

By law, generics must have the same active ingredient and the same action as the brand-name version, which allows them to piggyback on the original safety and efficacy trials. But generics do have different inactive ingredients, which can affect how they are absorbed into the body. Generics can produce blood levels as much as 20% below or 25% above that of the original drug and still be considered "bioequivalent," according to Food and Drug Administration guidelines.

Some patients are more sensitive to those differences than others, and people who experience problems with medications are advised to contact their doctors, the drug manufacturer and the FDA's MedWatch.

Wellbutrin, made by Biovail Corp. of Canada and marketed by GlaxoSmithKline PLC, is one of the best-selling antidepressants in the U.S., with sales of $1.8 billion in 2006. The FDA approved a generic version of Wellbutrin XL 300, a long-acting once-daily version, in December 2006. The generic, named Budeprion XL 300, soon accounted for roughly 40% of the one million monthly prescriptions for the antidepressant.

But patients soon started logging complaints about Budeprion at, a Web site that has become a clearinghouse for medication gripes. "We've received hundreds of complaints about generic drugs in general. But with this one drug, all of a sudden -- kaboom -- right after it was approved," says Joe Graedon, a pharmacologist who runs People's Pharmacy with his wife. Readers' postings cite side effects such as tremors, headaches, anxiety and sleep disturbances. Some consumers said their depression had returned, in some cases bringing thoughts of suicide. Many reported that their adverse effects stopped when they returned to the brand-name drug.

Mr. Graedon alerted the FDA. He also asked, which normally runs tests for dietary supplement manufacturers, to compare Budeprion and Wellbutrin. Using a test-tube test that some industry experts question, ConsumerLab found that Budeprion dissolves faster, releasing 34% of the drug within the first two hours, compared with 8% for Wellbutrin.

"If you get four times the drug in the first two hours, that's too much drug in the beginning and not enough for the rest of the day," says Mr. Graedon, who worries that what he calls "dose dumping" could cause seizures, a concern with the brand-name drug as well.

Complaints about Budeprion also were coming into the FDA -- at least 130 from December 2006 to January 2008, according to Andy Georgiades of Dow Jones News Service, who filed a Freedom of Information Act request.
Only four complaints were filed about two rival generic versions of Wellbutrin XL 300 that went on the market in June 2007.

The FDA conducted an investigation and reported last week that although there were "small differences" between the two formulations, "they are not outside the established boundaries for equivalence." The generic did reach its maximum blood concentration in two to three hours, compared to five to six hours for Wellbutrin, but the FDA said those differences "were not considered clinically significant."

What accounted for the consumer complaints? The FDA cited "the natural history of depression," in which some patients have a recurrence of symptoms even while on medication.


• If you have a bad reaction to a drug or concerns about quality, your first stop should be your doctor, who can file a medical report with the FDA.
• You can also submit a consumer report to the FDA's MedWatch program at You will be asked to describe the medication, the adverse event and some brief medical history. Your identity isn't requested. If you supply an email address, you will receive confirmation that your report was received. You can also speak to an FDA representative at 1-888-INFO-FDA .
• Contact the manufacturer or distributor. The FDA requires prescription and over-the-counter drugs to list contact information on the packaging.
• Return the medication to the pharmacist; use one you know and trust.
• www.PeoplesPharmacy.com4 also logs complaints about generic drugs, but these aren't counted as official FDA adverse-event reports.

Some critics say the FDA, in effect, was saying, "it's all in their heads." But they were more alarmed to read in the report that the FDA relied on tests comparing a lower dose of Wellbutrin and Budeprion -- 150 mg -- when it first approved the 300 mg version in 2006, and didn't have specific bioequivalence data on the 300 mg dose that had generated the complaints.

"Everybody involved in this whole chain -- pharmacists, physicians, insurance companies, drug-store buyers -- assumes the FDA approves every single generic formulation to prove that it isn't harmful," says Mr. Graedon.
"We learned last week that that's not the case."

The FDA explained that it didn't want to expose test subjects to the risk of seizures with the 300 mg dose. Bioequivalence tests are conducted on healthy people, not those who need the medication, and each gets just a single dose, so there is no chance to work up to 300 mg slowly, as actual patients are advised to do. Sandy Walsh, an FDA spokeswoman, says this is common procedure for testing antidepressants and antipsychotics.

"If we see scientific evidence that a product is not performing as expected, we will take action," Ms. Walsh says. "The FDA cannot offer examples where generics have not performed as expected because there have been none for the agency to report."

Deborah Jaskot, vice president for regulatory affairs at Teva Pharmaceuticals USA, which distributes Budeprion, says the ConsumerLab dissolution test was an invalid comparison, and that on all the accepted tests, Budeprion performed within the range of bioequivalence with Wellbutrin. Teva itself has received 101 reports of problems with Budeprion -- out of 4.5 million prescriptions written -- and hasn't heard reports of unusual smells, a spokeswoman says.

Ms. Jaskot also says Web sites that collect complaints about drugs "are doing the public a disservice." If consumers have problems with their medications they should "tell their physician, tell the manufacturer, tell the pharmacists, tell the FDA -- that's the only way these can get acted on and evaluated for veracity," she says.

But what if you complain to the FDA and are told, in effect, that your concerns are insignificant? As with so many other areas in health care, consumers have to be their own regulator and their own chief advocate.

"Consumers need to know that there are variations between generic drugs and brand-name drugs, and from one generic drug to another," says Wayne Pines, a former FDA spokesman who now consults for drug companies. "This is an area in which the patient has to be really self-protective, to be sure that they are getting the therapeutic effect that is best for them."

If you are taking a medication for a long-term condition, Mr. Pines advises staying with the version you are stabilized on. Some pharmacies sell generic versions interchangeably; tell your pharmacist you want to stay with the same one.

If you need to switch to a generic from a brand name for cost reasons, monitor your symptoms and review them with your doctor. Assess whether it's worth it to you to pay more. (There are some medications, particularly for thyroid and blood conditions, in which substitutions are never advised.)

The Graedons also recommend asking for copies of your lab reports, so you can help your doctor monitor any changes in your condition.

Be alert to changes in smell or appearance of your medications. Tell your doctor, pharmacist and the manufacturer if you notice anything odd.

Dr. Zealberg, however, is still waiting to hear back from the pharmacy that sold his patient blank pills.

The robot will see you now. At least in the operating room, where more and more often robots stand between doctor and patient, the New York Times reports. http://Louis2J2Sheehan2Esquire.US

At many hospitals robots, under the control of doctors, are performing some of the precision work of prostate and gynecological surgery. In their favor, robots’ “hands” don’t shake, don’t tire and can make precise cuts in tiny places. Robots don’t care about X-ray exposure or need days off either.

But how well are medical robots complying with the Three Laws of Robotics as codified by the late sci-fi author and Health Blog hero Isaac Asimov? Let’s take a look at Intuitive Surgical’s da Vinci robot, featured prominently in the NYT’s piece.

1. A robot may not injure a human being or, through inaction, allow a human being to come to harm.

Robots aren’t perfect, but, let’s face it, neither are humans. A quick check of the FDA’s database of problems reported for medical devices turns up a few, but not a ton, of complaints about the da Vinci. Among the recent ones, the robotic scissors in a prostate surgery case malfunctioned, filling the O.R. with the smell of garlic, but the patient wasn’t harmed.

Some fatalities were reported to the FDA recently, but it wasn’t clear they were related to the robot, such as the death of a hysterectomy patient from sepsis four days after surgery.

2. A robot must obey orders given to it by human beings, except where such orders would conflict with the First Law.

Again, the FDA database shows a few cases of an obstinate or malfunctioning robot, but not a revolution of machines against their masters. One user reported to the FDA that a flurry of error codes led a surgeon to abort a robot-assisted prostate procedure and continue the old-fashioned way last year–no harm to the patient. Intuitive Surgical, maker of the robot, later fixed the device, the report said.

Another report says one of the robot’s arms stopped working during a cardiac procedure. The surgeon made another incision to insert another instrument to complete the operation, but a re-boot of the machine by a company rep revived the robotic arm. The surgeon completed the operation without the robot balking again.

3. A robot must protect its own existence as long as such protection does not conflict with the First or Second Law.

Robots are thriving, and their survival instincts appear strong. Despite the da Vinci price tag of about $1.3 million, on average, “it is rapidly becoming unusual for a urologist to operate without using one,” the Times reports.

Rather than conflicting with the first two laws, the robots may be bumping into the iron law of hospital profitability. Health technology consultant Winifred Hayes tells the Times that most hospitals and clinics are losing money or not making much on their investments in robots.
“The real story is that this is a technology that has been disseminated fairly widely prematurely,” she adds.

It was like a college mixer, a classroom full of young men and women seeking a recipe for romance.

They had assembled for the first class of “Love Relations for Life: A Journey of Romance, Love and Sexuality.”

There was giggling and banter among the students, but that was all part of the course as their teacher, Suki Tong, led them into the basics of dating, falling in love and staying together.

The course, in its second year at two polytechnic institutes, is the latest of many, mostly futile, campaigns by Singapore’s government to get its citizens to mate and multiply. Its popularity last year has led to talk of its expansion through the higher education system.

“We want to tell students, ‘Don’t wait until you have built up your career,’ ” said Yu-Foo Yee Shoon, the minister of state for community development, youth and sports, at a news conference in March. “Sometimes, it is too late, especially for girls.”

The courses are an extension of government matchmaking programs that try to address the twin challenges embodied in a falling birthrate: too few people are having babies, and too few of those who are belong to what Singapore considers the genetically desirable educated elite.

Over the past 25 years, the mating rituals organized by the government — tea dances, wine tastings, cooking classes, cruises, screenings of romantic movies — have been among the country’s least successful social engineering programs.

Last year Singapore’s fertility rate fell to a record low of 1.24 children per woman of childbearing age, one of the lowest in the world. It was the 28th year in a row Singapore had stayed below the rate of 2.5 children needed to maintain the population.

But even a replacement-level rate would not be enough for today’s planners.
The government recently announced that it was aiming to increase the population by more than 40 percent over the next half-century, to 6.5 million from the current 4.5 million.

“Teaching our youth in school how to fall in love” is a good solution, wrote Andy Ho, a senior writer at The Straits Times, a government-friendly newspaper that does its best to help out in Singapore’s many campaigns.

In 1991, for example, when the government began offering cash bonuses to couples with more than two children, the newspaper printed tips for having sex in the back seat of a car, including directions to some of the “darkest, most secluded and most romantic spots” for parking.

It suggested covering the windows with newspapers for privacy.

Singapore is known for its campaigns of self-improvement, including efforts to get residents to be polite, to smile, to be tidy, to speak proper English and to not chew gum.

In 1984, the country’s master planner, Prime Minister Lee Kuan Yew, declared that too few of the country’s most eligible women, those with college degrees, were marrying and having children. He set up the Social Development Unit to address the problem, and since then the government has been the country’s principal matchmaker.

In addition to its tea dances and moonlight cruises, the agency acts as a lonely hearts adviser, with an online counselor named Dr. Love and a menu of boy-meets-girl suggestions on its Web site,

“Guys, girls notice everything!” the Web site offers in one of its dating tips. “Comb your hair differently and they notice. Change your watch and they notice! Skipped your morning shower and sprayed on deodorant to cover the smell — they notice! What does this mean? Well, bathe regularly, change something about yourself, be observant, and compliment the lady.”

Mr. Lee himself acknowledged how silly some of this may seem.

“Never mind the hullabaloo in the press, all the foreign correspondents writing that a crackpot government is trying to interfere in people’s lives,” he said when he inaugurated the Social Development Unit. “If we continue to reproduce ourselves in this lopsided way, we will be unable to maintain our present standards.”

In other words, said Annie Chan, director of a matchmaking agency, “Our government wants smart ladies to meet smart guys to get smart children.”

But in Singapore it is impossible to get very far from thoughts of money and the workplace.
These guys may have other things on their minds besides romance and babies.

“Some people say if you’re a smart guy you should marry a smart woman who can help you with your finances and career,” said Ms. Chan, whose agency is called Club2040 and who has worked under contract for the Social Development Unit.

Singaporeans quite seriously describe their society as being driven by a local concept called kiasu, a desire not so much to get ahead as to not lose out. That concept might be applied, for example, to a person who pushes ahead of everybody else to get into an elevator.

This single-mindedness, in life as in elevators, seems to leave little room for social graces or for romance or procreation.

“The E.Q. here,” said Ms. Chan, referring to an emotional quotient of social skills, “can be appalling.”

But even while working on the solution, Ms. Chan seems to be part of the problem. She is 39 and has been married for four years, but said she did not have the time or energy to have children.

It is a lot to ask of a college course to break attitudes like this. Three 20-year-old graduates of last year’s inaugural course at Singapore Polytechnic still seemed imbued more with kiasu than romance.

Despite everything their teachers had told them about multitasking work and love, none was in a relationship. And nothing they had heard in class seemed to have dented their stereotypes about the opposite sex.

“I’m not open to relationships in school,” said Wei Shan Koh, a former student who works as a teacher’s aide. “Boys in school are not my cup of tea. They are male chauvinist pigs. They’re annoying and childish. And they won’t give in to you. They’re just not mature.”

Another former student, Tian Xi Tang, was quick to respond.

“I think girls’ ideas are a bit childish, or you might say girlie,” said Mr. Tian, who hopes to become an engineer. “It’s a matter of pride. Guys are more outspoken. We don’t like a girl to be more outspoken.”

Kamal Prakash, who hopes to be a lecturer in mathematics, gave voice to what appears to be the common theme here, among both young people and their elders.

“I am not interested now in love relations because I want to continue my studies,” he said. “If I concentrate on love relations, I won’t be able to concentrate on my studies.”

With his Mercedes-Benz and his fine clothes, Josef Fritzl looked every inch a property owner, neighbors in this tidy Austrian town said Monday. Even when running errands, they said, he wore a natty jacket, crisp shirt and tie.

Mr. Fritzl’s apartment house, its back garden obscured by a tall hedge, was his kingdom, one neighbor said, and interlopers were not welcome. On Monday, investigators in white jumpsuits combed the house and garden for clues.
The authorities said Sunday that Mr. Fritzl, 73, had kept one of his daughters imprisoned for 24 years in a basement dungeon, where she bore him seven children.

The daughter, Elisabeth, now 42, is in psychiatric care, along with two of her children. Her eldest daughter, Kerstin, 19, who was also kept in the basement and whose illness pulled apart Mr. Fritzl’s secret after he had her taken to a local hospital, was in a medically induced coma and was in critical condition, the authorities said.

The authorities said Mr. Fritzl confessed Monday to imprisonment, sexual abuse and incest. The case has left this town of 22,000 people, 80 miles west of Vienna, in stunned disbelief. Neighbors milled around the three-story apartment building on Monday, watching the investigation unfold and asking how such an atrocity could have occurred in their midst.

“One cannot comprehend the dimension of this,” said Doris Bichler, 34, a neighbor who was walking with her daughter. “Natascha Kampusch was bad, but this is of a totally different scale.” Ms. Bichler was referring to the notorious kidnapping of an Austrian schoolgirl, who was hidden in a windowless cellar for eight years until she escaped in August 2006. Until now, the Kampusch case was considered by many as the epitome of depravity in the post-World War II history of this country.

But as details of this latest case filter out, it seems even harder to fathom than Ms. Kampusch’s abduction, involving nearly a quarter-century of confinement and sexual abuse, and the birth of seven children, three of whom never emerged from the cellar into daylight until last week.

It also raises a troubling question: Why did two such horrifying crimes occur in the same period in Austria, known as a tranquil, picture-book land?

There seems no easy answer — and Austrian officials, while insisting that similar crimes had occurred in other countries, said they were struggling to make sense of Mr. Fritzl’s singular misdeeds.

“He was man of stature,” Franz Polzer, the chief of the criminal investigations unit for the Province of Lower Austria, said at a news conference here, holding up a photograph of Mr. Fritzl, a heavyset, gray-haired man dressed in black.

“He led a double life,” Mr. Polzer continued, “with one family of seven children, with his wife, and a second family of seven children, with his daughter.”

The police described Mr. Fritzl as an authoritarian figure who had brooked no dissent.

Trained as an electrician and an engineer, Mr. Fritzl owns the small apartment building, renting out a few apartments and living on the top floor. Over many years, he built an underground world for his captives in a warren of cramped, windowless rooms. He provided them with food and clothing, bought outside town to avoid suspicion.

Photographs show a miniature bathroom, finished with tile and wood trim on the ceiling. A claustrophobic passageway leads to a bedroom.

The chamber was accessible through a four-foot-high door that opened with a remote-control device, for which only Mr. Fritzl held the code.

The police said his wife, Rosemarie, 68, had no inkling of his secret life, believing that their daughter had fled the family for a cult and was unable to take care of her children. Mr. Fritzl forced Elisabeth to give up three of the children as babies, and he and his wife raised them. A seventh child, a twin boy, died soon after being born; Mr. Fritzl told the police he threw the body in an incinerator, the authorities said.

“You have to imagine that this woman’s world fell apart,” a local official, Hans-Heinz Lenze, said of Rosemarie.

At the news conference, officials came under sharp questioning about how the situation could have remained unknown to the authorities. After Mr. Fritzl and his wife began taking care of Elisabeth’s children, social workers visited their home several times.

Officials defended themselves hotly, saying that if Mr. Fritzl was able to keep his wife ignorant of his crimes when she lived upstairs from the cellar, how could outsiders have guessed?

Neighbors expressed similar bafflement.

“You’re amazed that something like this could happen in your neighborhood,” said Günther Pramreiter, who runs a bakery next door to the Fritzls’ building. He said the couple, or their adopted children, came in every other day to buy rolls.

By most accounts, the three children who grew up in the Fritzls’ care were well-adjusted, each learning to play a musical instrument.

Karl Dattinger, 20, a volunteer firefighter, recalls that one of the daughters, Monika, had received a perfect score on a test of fire safety he gave at their school.

Matthias Sonnleitner, who manages a hardware store, said his children had taken martial arts classes with the Fritzl children. Rosemarie Fritzl occasionally came to his store to buy curtains, he said.

Even two of the three children imprisoned in the cellar were surprisingly healthy, if pale, according to the authorities. Elisabeth taught them to speak German, and they had access to a television.

The television played a key role in untangling the case, the police said. After the 19-year-old, Kerstin, was taken to the hospital, authorities appealed for her mother to come forward. Elisabeth saw the broadcast and persuaded her father to release her and the other two children living with her. Officials declined to give a prognosis for Kerstin.

Among people in the Fritzls’ neighborhood, there was a disquieting sense that more could have been done.

“I think the authorities are overworked and weren’t able to follow up every lead,” said Franz Jandl, 50, who owns a shop across the street from the apartment. “For a little country, to have this kind of thing happen a second time is a catastrophe. It’s just very sad.”

Spain's National Court has decided against extraditing the former Argentine president María Estela Martínez de Perón, 77, to Argentina, where she is wanted on charges of human rights abuses during her presidency in the 1970s. In two rulings, the court said that the charges did not constitute crimes against humanity and that the statute of limitations for the offenses of which Ms. Perón, known as Isabelita, is accused expired after 20 years. The rulings may be appealed. Ms. Perón was the third wife of Gen. Juan Domingo Perón and vice president when he died in 1974. She then led the country for two tumultuous years before being deposed in a military coup. She has lived in Spain since 1981.

The number of people traveling the globe for medical treatment likely is far lower than commonly assumed, but there remains potential for huge growth in the industry, according to a study by consulting firm McKinsey & Co.

Just 60,000 to 85,000 patients a year travel to another country expressly for inpatient hospital care each year, according to the study, which is scheduled for release Tuesday., most aren't seeking low-cost care in the developing world, the phenomenon that has garnered considerable attention lately. Instead, many of the medical tourists seek the latest treatments available in the U.S. and other industrialized countries.

The consulting firm analyzed the behavior of nearly 50,000 patients using data from unidentified hospitals around the world, as well as government travel records and other information. The researchers also interviewed patients and hospital officials. They estimate the sample amounted to 60% to 80% of the world-wide market.

The figure contrasts sharply with those often used by medical-tourism marketers -- one said Asia attracts 1.3 million medical tourists a year -- and anecdotal accounts. "There's been an enormous amount of hype," said Paul Mango, who heads McKinsey's health-care practice. However, he noted that the report estimates that the eventual market for Americans seeking cheaper care abroad at perhaps 710,000 procedures a year.

The Medical Tourism Association, a trade group in West Palm Beach, Fla., that represents hospitals, travel agents and brokers, among others, avoids trying to quantify the industry's size precisely because there is no consistent definition of medical tourism, said Chief Operating Officer Renee-Marie Stephano. And, citing the complexity of collecting comprehensive data, she cautioned that McKinsey's numbers are likely to be similarly flawed because they involve only a sample of facilities and look at hospital admissions. "A large portion of the medical-tourism industry is based in cosmetic procedures and dental care, which are not performed in hospitals," Ms. Stephano said.

To arrive at its estimate, Mr. Mango's team focused on patients traveling expressly for inpatient hospital care and excluded several categories that the consultants said were commonly included in higher estimates. Those include expatriates seeking treatment in the countries where they live, tourists seeking unexpected medical attention, and some patients traveling short distances across borders for care not available nearby in their own country.

About 40% of "medical travelers" identified in the report are patients, largely in developing countries, seeking top-notch medical care, primarily in the U.S. Another 32% sought better care than was available at home. About 15% sought to circumvent waiting times at home, particularly in Canada and the United Kingdom, Mr. Mango said.

Americans and others seeking lower-cost care for medically necessary procedures accounted for about 9% of the total, the consultants estimate.
Elective procedures such as cosmetic surgery accounted for about 4%.

Still, much of the growth potential lies in patients seeking cheaper care in the developing world, the report concludes. It estimates that about 710,000 procedures a year -- procedures that currently bring $35 billion of revenue -- could be done overseas at a savings of about $15,000 a procedure.

But about 80% are likely to continue to be more cost-effective to perform in the U.S. Most Americans seeking cheaper care overseas now are uninsured, and Mr. Mango said the "No. 1 factor" is whether insurers, employers and the government will begin encouraging foreign treatment.

Some people want a little more out of their vacation than a fruity drink served poolside. Diving with sharks in South Africa, for example. Or living among penguins for five days in Antarctica. Or paddling in a canoe down a crocodile- and hippopotamus-infested river in Zambia.

For those people, the travel company Abercrombie & Kent has created a series called Extreme Adventures. Starting next fall, 15 adventure packages will be available in countries that range from Norway to Kenya to Nepal, featuring activities that include hiking, dog sledding, bungee jumping and cross-country skiing.

The first trip is scheduled for Sept. 28 through Oct. 6 and will take participants on foot through the Selous Game Reserve, a nature sanctuary and Unesco World Heritage site in Tanzania with elephants, black rhinoceroses, cheetahs and giraffes (from $9,830 a person, including airfare).

Egyptians mostly ignored the April 8 local elections to fill 52,000 places on municipal and village councils. Seventy percent of the seats were earmarked for [Hosni Mubarak]'s National Democratic Party because they were "uncontested." Mubarak's son, Gamal, happens to head the NDP.

Recalling the failed policies of the Shah of Iran, Mubarak has defeated the non-Islamist opposition, leaving the Muslim Brotherhood as the only credible voice of reform. This is the same toxic movement, founded in 1928, whose world-view spawned al-Qaida and Hamas.
It wants Shari'a law imposed in Egypt and relations with Israel broken off. Prudently, the Brotherhood eschews violent revolution, patiently waiting for power to fall into its hands. Despite Mubarak's machinations, Brotherhood- supported "independent" candidates captured 20% of the 454- seat parliament.

How well the regime feeds, clothes and employs its population, how swiftly it creates a civil society and system of representative government should be of foremost concern to Israel. Mubarak is mistaken in emasculating the moderate opposition, misguided in trying to "out-Islam" the Brotherhood by persecuting homosexuals. He is wide off the mark in allowing Egypt's media to demonize Jews and Israel. It took him too long to realize that letting Hamas bleed Israel was ultimately not in Cairo's interest.

American International Group joined the ranks of the credit crisis's biggest losers Thursday, reporting a $7.81 billion first-quarter loss and announcing plans to raise $12.5 billion in fresh capital as losses on complex securities soared.

The insurer said profits were hurt by a $9.11 billion hit on its portfolio of derivatives sold to hedge securities that have plunged in value and $6.82 billion in losses on investments. AIG reported another $6.82 billion in impairments that for accounting reasons only showed up on its balance sheet.

The blows brought AIG's total write-downs and losses from the credit crisis to more than $30 billion, with another $9 billion-plus in damage just to the balance sheet, putting the insurer in the same league as UBS AG, Citigroup Inc. and Merrill Lynch & Co.

The massive losses spooked investors and could deal a blow to optimists who have bet the worst of the crisis has passed.

The cost of protecting AIG's bonds against default soared after the announcement, and the insurer's shares plunged 8.7% to $40.30 in after hours trading. Standard & Poor's cut its credit rating on AIG one notch to AA- and put it on watch for a further downgrade.

"Although we expected that AIG would have some losses in the first quarter, the level of the additional losses exceeds these expectations," S&P analyst Rodney Clark said in a release.

The insurance company reported a net loss of $7.81 billion, or $3.09 a share, compared with year-earlier net income of $4.13 billion, or $1.58 a share.
Analysts polled by Thomson Reuters were expecting a much smaller loss of 76 cents a share.

To repair the hole opened by the losses, AIG on Thursday launched a $7.5 billion offering of common stock and other equity securities. Another offering of hybrid securities will follow later. AIG had a market capitalization of $110.19 billion at the close of trading Thursday.

Even as it sought more capital to repair its balance sheet, AIG raised its quarterly dividend 10%, to 22 cents a share.

"While we anticipated a difficult trading environment, the severity of the unrealized valuation losses and decline in value of our investments were beyond our expectations," CEO Martin Sullivan said in a release.

AIG has multiple exposures to the housing crisis, and results were weak across the board. Its financial-products unit manages its derivatives portfolio of credit default swaps written on collateralized debt obligations backed by residential mortgages. The financial services unit swung to an operating loss of $8.77 billion in the first quarter from a profit of $292 million a year earlier.

The company's asset management unit posted an operating loss of $1.25 billion versus profits of $758 million a year ago amid losses on hedges, lower investment returns and depreciation expenses related to real estate investments acquired late last year.

The life insurance unit swung to an operating loss of $1.83 billion from a profit of $2.28 billion on hedging losses and damage to investment income from "volatile capital markets." Operating income in AIG's big general insurance operations fell 57% to $1.34 billion.

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