Cameras Save Lives!

The rioting this week in Ferguson, MO, has deeper roots than I want to explore right now. But the spark, the August 9 shooting of a black teenager, Michael Brown, by a white cop, Darren Wilson, is something that happens all too often.

The real story is murky at best. Maybe the confrontation was violent in two directions. Maybe Brown was running away when the first shots were fired, maybe he was charging the cop or maybe he was bowing his head in surrender or pain.
There are many reports of what exactly happened between Mr. Brown and Officer Wilson.

What we do know is that the cop involved was not wearing a body camera. A report from the Police Foundation says there’s a strong calming effect of body cameras:

“The findings suggest more than a 50% reduction in the total number of incidents of use-of-force compared to control-conditions, and nearly ten times more citizens’ complaints in the 12-months prior to the experiment.”

Why? Two reasons: because cops are less likely to overuse force when they are being recorded; and because arrestees, when confronted with video evidence, often retract their complaints.

This has been analyzed in the New York Times and National Public Radio, even before Ferguson.

The cameras cost some money, of course, and the data needs secure, third-party storage. One such storage site is The ability to use body-cam data in court requires chain of custody and security from tampering, which isn’t free. But that cost must be balanced against the liability costs saved from citizen-police complaints, and the potential savings in court costs if arrested people are confronted with immediate evidence that could influence their willingness to plea-bargain.

And the economic cost is trivial compared to the potential value of improving relations between police and the communities they are supposed to be protecting and serving. Cameras aren’t magic, and problems – especially racial tensions – won’t fade immediately. But isn’t preventing another Ferguson, another Rodney King, another Amadou Diallo, worth something?

Not ready for Hillary?

For a while, now, there have been speculations and prognostications about whether Hillary Clinton will run for the presidency in 2016. The PAC “Ready For Hillary” was founded for the express purpose of persuading her to run. Its first public appearance? Less than a week after the 2012 re-election of Obama. (Facebook page- joined November 10, 2012)

If we look back to 2008, there was also a sense of inevitability – probably carefully cultivated – about HC being the Democratic nominee. Then that other guy showed up.

At the time, I had mixed feelings. I figured Obama was inexperienced as a first-term senator, and that he could benefit from waiting a cycle or two. But I didn’t like Clinton’s employing the personal negatives that she had so decried when they were used against her husband. And I wasn’t willing to accept the “inevitability” narrative. And I worried that the Clinton name, and her femaleness, would cause the right wing to oppose her with venomous bitterness without regard for policy ideas.

Okay, so that last worry happened anyway…

But here’s why I’m still not ready for Hillary.

First of all, I think speculation that started more than three years before the Iowa caucuses is a little early. Can we wait and see how the 2014 midterm elections play out?

Second, I want to see real competition. Having the 800-pound gorilla of politics in the race could crowd out other candidates. And I don’t even know who they are yet!

Third, I’d like to see at least one of those candidates be a truly progressive candidate, one who will work hard for the poor and stand up to Wall Street. I’m pretty sure that “standing up to Wall Street” isn’t a top priority for an HRC presidency. And she isn’t really a progressive.

I started this draft in November 2013. Never got much past the Elizabeth Warren commentary from the New Republic, above. But then I saw this morning that she is still playing coy.

Come on. “I am considering it, but I’m not committed one way or another, yet.” Is that too much to say? How about, “I’d like to see a vigorous and robust primary campaign, in which many Democratic candidates put forth their visions for the future of this country.” Or “Ask me after the November midterms, and I’ll be ready to answer you then.”

Or even, “Yeah, I’m going to run. Bring it!” At least that way we’d have a couple years for potential primary opponents to consider if they wanted to support her or mount their own challenge. And the barrage of negativity from Fox News would be, at the very least, old news by the time voters really start paying attention. If she’s worried that that the inevitable attacks might drop popularity ratings, then why not give herself time to claw back?

So, I’m ready to see who else is out there. Not that I don’t support her. I hope she’d be tougher in working with a republican-controlled House than Obama was. Senator, Secretary of State, and of course one of the more experienced White House hands. I think Hillary is ready, but I’m not, quite, yet. Let’s watch some debates, see some retail politics, and have a competition instead of a coronation.

Brains and personhood – at the end of life

Two recent posts in the Facebook feed of DeFund the Komen Foundation, plus a life event that happened to people I know, got me thinking about brain function and what it is to be a living human. (Also the vagaries of health care and insurance.)
All of these are very sad events, and I hope never to have to go through them. I’m so awed at the strength and resilience of the family I know, and I hope the other families affected can share their strength in the face of catastrophe.

In one case, the most likely for the general public to have heard of, a teenage girl suffered serious complications after a tonsillectomy and eventually was declared brain-dead. Her family is resisting this diagnosis and has planned a public march for her.

In a second case, a woman in Texas who suffered some kind of aneurysm cannot be removed from life support because she is pregnant. According to her husband, this is against her expressed wishes.

Finally, a little over a year ago, a local man suffered a heart condition that left him severely brain-damaged from oxygen deprivation. Jim’s body hung on for ten months, from ICU to nursing home and finally to hospice care. While Jim was not brain-dead, it gradually became clear that he could never recover and that his life would be a spiral of infections, hospitalizations, and very small moments.

In each of these cases, a beloved family member suffered a sudden problem that caused their brains to lose the ability to maintain the person they used to be. The responses of the families and medical communities to these events show such a range of attitudes toward life and their loved ones. The McMath family is shocked and refuses to accept the “cold” diagnosis, at least until Jahi can be examined by an independent neurologist. The Munoz family is in the opposite situation, but the state of Texas is insisting on keeping Marlise Munoz’s body functioning for the next five months to nurture the 18-week-old fetus. And the Blum family lost a terrific husband and father, in steps.

The brain supports our personal self in a way that, for example, the kidneys do not. The classic philosophical question comes from the possibility that medical science found a way to transplant the fully functioning brain of person A into another body, B. Would you say that Person B got a brain transplant, or Person A got a body transplant? (In a Larry Niven short story, the body transplant answer was used as a perfect disguise by an “organlegger”)

Is Jahi McMath dead? By some medical definitions, pretty much. Or maybe she’s just “mostly dead.” But her family says, she is warm and soft and still alive. Marlise Munoz isn’t dead, either, but Erick knows she wouldn’t want to be maintained by machines. For Jahi, the hospital wants to let her body stop supporting a brain that can no longer maintain the person Jahi. Her family is, as yet, unwilling. Erick Munoz, on the other hand, is ready to say goodbye to his beloved Marlise, in accordance with her known wishes. And as for Jim, his “Jimness” left in late November 2012, but for tiny embers of recognition, and the rest of his body outlived him by ten and a half months.

For each of these people, their essence was gone at a different time than their biology quit functioning. The brain is where we are, and the body has to support it to keep us going. For religious people, there is a question as to when, exactly, the “soul” separates from the body. Cases like these make it harder to pinpoint a time or an event. I think Jahi’s family will need to make that decision – one of the news stories referenced a minister. I don’t know what the Munoz family thinks, religiously.

I was able to chat with Jim for a little while when he visited our house on one of his last evenings as Jim. Of course, no one knew that at the time. And I never saw him again, except in a few photos from his Caringbridge page (linked above). But his family came to accept that Jim-the-person wasn’t really in Jim-the-body any more. They were fortunate not to be in a redneck state like Texas that might have interfered with their decisions because of someone else’s religious views, or because a callous hospital might prefer a wrongful-death claim to extended life support.

When my body can no longer keep my brain going enough for there to be Dave, I’m gone. Take the parts I’m no longer using, if someone else can benefit from them. Recycle paper and pancreases, cans and kidneys. And, support stem-cell research for neural injury. Jim’s widow wants you to.

Colonoscopy and health care…

I just went through that ritual that officially makes me middle-aged: the colonoscopy. It wasn’t a hugely fun event, but guess what my out-of-pocket was? About thirty bucks, on the over-the-counter drugs needed for the “cleansing prep” plus a couple jugs of Gatorade to wash it down. Zero co-pay for the procedure itself, because my insurance calls it “preventive care”.

If I had to set rates, I’d figure that there were about 1 1/2 hours of skilled nursing time, 1 hour of MD time, a couple low-skilled hours for staff to clean up, receptionist, laundry, etc. Then add another half hour of clinician time and half an hour of MD time for the CLS and the pathologist who get the biopsies.
Then there’s the consumables: IV equipment, gloves, absorbent pads, wipes, etcetera; plus the liter of saline with Versed and Fentanyl.
Add in use of the equipment, figuring most of its many-thousand dollar cost to be spread over the thousands of people who use the facility.
Finally, add in the cost of the space: a miniscule portion of the cost of the building, utilities, etc.

So, that ought to come up to a pretty expensive total. Maybe $1200-$1500? Who really knows: it’s worse than airline tickets, where at least the price is “take it or leave it” and you can (usually) go with a competing carrier.

When I had my cat to the vet, to get two cysts removed and biopsies, we were given an advance statement with a range of itemized prices: “we might not need this, but here’s what it is if we do”. Granted, this was elective surgery, but Sandy counts as a family member. With a 100% out-of-pocket cost, it made sense to know in advance. It came to about a thousand bucks, total. I bet a similar cyst removal and biopsy for a human patient would be a lot more, even though the human wouldn’t need general anesthesia and (probably) wouldn’t need to be shaved or wear the “collar of shame”.

The New York Times ran this comparison of costs, in which I discover that $4000 is typical in Minnesota.
I’m looking forward to logging on to my insurance web site next week to find the “explanation of benefits” to find out what happens with all the Monopoly money that gets shifted around. I’ll write a follow-up when that happens.

Meanwhile, there’s an interesting discussion happening on a friend’s Facebook feed about the opacity of the system and unpredictable, ridiculous charges:

How as a doc am I going to know? They don’t tell me, insurance companies cover differently and have different co-pays, and I’m busy keeping changing protocols, med regimens, lab goals, health maintenance guidelines, names and faces and health histories straight, plus doing extra jobs I was never trained in am nor paid for, like transcription and coding. Most of the money goes to the middle men in any case. It is truly a broken system.

Random FOAF:

Yeah. My son’s jammed finger (from football) was not broken and it healed uneventfully with a little splint. If I didn’t have insurance, we’d just have spent $10 at Walgreens on a splint and had the same outcome as going to urgent care (which bills more like an ER than a doctor’s office visit), getting x-rays, and having a follow-up appointment. I think the total billing was probably about $3000.

same MD:

(To:) [random FOAF]: if it had been broken and needed pinning to heal well, and not pinning it right away would have meant re-breaking it, what then? I can see waiting a day or two before coming in, but I wouldn’t blame the urgent care doc for doing what was warranted.

(To:) [another name redacted]: I know visits cost in the hundreds, labs under 100 unless obscure send-outs, xrays/ultrasounds in the 100-200 dollar range and MRIs between 1000-2000. I do look at whether pts have insurance or not, but I try to make an appropriate recommendation based on the facts/exam and give other options with risks/benefits. Should I avoid doing a stress test on that guy with chest pain and a family hx of CAD because he doesn’t have insurance?
If I am found to be constantly undercoding my uninsured visits, I can also be charged with fraud. Good times.
I intentionally work for a lower salary to work in a hospital system that has free care, discounted care, and helps folks find insurance if they qualify. I am not the bad guy. Neither are most of my colleagues.

another MD, same thread:

So a couple of thoughts from my 20 years of practicing medicine:

First if [kid] was cared for by the same doctor who put his cast on, then there should have been a “global” fee – to care for the fracture from beginning to end. There could be some charges for extra x-rays, but for the most part it should have been a set fee.
Taking an x-ray at the completion of treatment is standard of care. It is very important to make sure the healing occurred appropriately. If not, there can be serious consequences later.

The cost of medicine is definitely way out of control. However, that is not the fault of any one physician. The system is definitely broken, and there has to be some type of fix for it. I’m not saying that Obamacare is the best way, but something has to change. Parts of the affordable care act are good, others may not be. Much of it is unknown as to how well it will work. . . . But at least there is an attempt to fix it.

In terms of costs, there can be some estimates prior to visit. However, the art of medicine is deciding what is needed and what is not. Sometimes the workup is very simple, other times it needs to be very extensive. The costs are often hard to estimate, unless it is a very straightforward visit.

I truly believe that part of the broken system is all of the extra tests run due to litigation issues. This country is sue happy, and physicians often practice defensive medicine. There is a science of medicine, and an art of medicine. I think good physicians practice the art of medicine supported by science. Listening to the patient and taking time is very important, something I always try to do. Hopefully your physician does the same.

*FOAF = friend of a friend
CLS = clinical laboratory scientist

Bioctechnology, colonialism, and the spice trade

Genetically engineered yeasts are producing high-value organic chemicals by incorporating biosynthesis from other plants. This is way cool from a scientific point of view, as the bio technologists engineer the plant mechanisms that make valuable flavors like vanillin or an anti-malaria drug.

But the article discusses the negative impact bioengineered products like this might have on third-world growers of these spices and flavorings. Right now, the “real” vanilla extract you buy comes from places like Madagascar where the vanilla beans are grown. Artificial vanilla extract, mostly pure vanillin, has a less interestingly complex flavor. The artificial flavor certainly competes with natural bean vanilla, but the bioengineering is just a (potentially) better way to make the product than the current synthesis from wood pulp by-products or petrochemicals.

Where does the colonialism come in? Vanilla (and chocolate) is native to Central America. It was brought back to Europe in the 16th century as the expanding trade empires sought new flavors. Gold is a scarce and finite resource. Exotic spices are renewable and, while less glamorous, were probably a better business proposition in the long run. The vanilla plants were transported around the world to other tropical areas where they could be grown away from the Spanish empire. Over a few centuries, vanilla plantations developed to supply the demand. However, the huge demand for vanilla flavor led to several syntheses of vanillin.

Currently, natural vanilla only accounts for some 15% of the market. The first synthesis was from clove oil, which seems like it would limit the value added since you’re starting with another tropical spice. The synthesis from lignin (wood pulp waste) was dominant for most of the 20th century, but now the major method is from guiacol or, as organic chemists might name it, ortho-methoxyphenol.

So, should we be concerned about the poor vanilla farmers? Not really, since the demand for vanilla is still much higher than the growers can supply. And really good synthetic vanillin still won’t have the complex flavors that the natural beans generate through hundreds of other components.

I say, relax and be happy. The vanilla story is just a microcosm of what biotech can do – and better chemicals are no doubt in the pipeline. Now I think I might just have some ice cream….

Our motto: Surfing Wikipedia so you don’t have to.

Update: while I’m here enlightening the masses, my loving family has EATEN ALL THE ]{}}#*^{#+ ICE CREAM!!!!!!!!

“It seemed like a good idea at the time” – Plastics additives

Today’s topic is a scary-nerdy one, endocrine-disrupting chemicals and choices. This column discusses the manufactured controversy, but so many people hear big scary science words and get confused.

Like a lot of problems, this one started as a solution to something else.

We’ve been here before. Lead in gasoline was a terrific solution to making gas burn more efficiently on cheaper fuel. (Remember the Fred Flintstone cartoon where the gas pump was a dinosaur named “Ethel”? That was a reference to tetra-ethyl lead.) Oops, turns out lead is bad for you and causes Tea Party activists brain damage. Well, that’s a problem, so we had to ban leaded gasoline.
Chlorofluorocarbons were a great invention, making possible safe refrigeration and air conditioning, so food spoilage was reduced. They’re so safe you can even use them in inhalers for asthma medicine. Unfortunately, they are also responsible for ozone depletion. The greenhouse gas issue is the same. Fossil fuels have done great things for the economy and bad things to the environment.

In all these cases, the theme is the same. “It seemed like a good idea at the time.” And, in general, the problem solved was more significant than the problem created. What causes trouble is when we as a society, or the people who can make those decisions, refuse to modify the problem-causing part of their product or process. Usually, there is a burden of proof: if there is possible harm, then it is important to show the harm is real and that the benefits of alleviating the harm outweigh the cost of finding a solution. So, a significant threat from lead in gasoline was bad enough to force a change, and the change was not that onerous. For CFCs, the change of formula to a less-dangerous substance (decomposing before it can get up to the ozone layer and/or chlorine-free) was a technological and engineering hurdle. But it’s been solved with relatively little pain.

A more serious problem happens when the solution involves a more dramatic shift or even abandoning the problem-causing issue. Thus, the tobacco companies fought a long and vicious fight against the tobacco/cancer link, because the best (and generally viable) fix is to avoid tobacco. Similarly with fossil fuels, where the stakes are extremely high. Vast profits, and globally severe consequences, have made a bitter battle since there isn’t an easy replacement.

So the question for the plastics industry is, will you devote your efforts to searching for alternative additives, or to fighting to keep your existing processes? And the question for opponents is, how can you make a scientifically valid and publicly persuasive case that these additives are dangerous? Current standard tests for toxicity aren’t good at analyzing subtle hormone effects that may not show up for a generation or even two, and where the contamination is so low and so widely dispersed that the “background” level of problems is significant. (Actually, the same questions apply to genetically engineered crops!)

Right now, it seems like market pressures are having a far more significant impact than regulation or law. Look at the water-bottle selection at Target and they are mostly advertised as “BPA-free”. But that doesn’t help with the non-water-bottle market.

So, why are these chemicals are even around?

Background – Plastic Basics

Plastics are terrifically cheap and versatile materials, but they don’t always have exactly the right properties manufacturers need. By mixing other chemicals into the plastic, its properties like color, flexibility, sunlight resistance, or ability to be shaped and molded can be tweaked.
Imagine a huge pile of cooked spaghetti noodles, without sauce.

Dump it out onto a cookie sheet so you can spread them into a thin layer. Let the noodles dry out in their tangled mass and you have a decent model of plastics. You can imagine that you might get different properties from thick linguini vs. thin angel-hair pasta, or maybe the more tangly Ramen noodles or the more transparent rice noodles. Maybe you’d get different properties if you let them air-dry vs. oven-drying, and how dry are you going to get them? All the way back to the original state, or more leathery-tough?
But sometimes, instead of the brittleness of dried noodles, you might need a little flexibility. So, you add some oil to the noodles so they won’t be quite so dry and can slide past each other al little, as the mat of dried noodles bends. That works great, but after a while you notice that the olive oil you used isn’t quite as good as it could be, plus it’s attracting ants. Since you weren’t going to eat this stuff anyway, go ahead and use motor oil instead. Perfect!
Or maybe you want the noodle-plastic to be harder – okay, throw a little glue in there, or maybe some wagon-wheel noodles to increase tangling.

The polymer (meaning long chain of many molecular units) industry has gotten really good at finding the exact type of noodles and oil for whatever product it wants to make. The “oil” additives are called plasticizers. These are substances that improve the flexibility of a polymer so that a vinyl raincoat or a PVC plumbing pipe (same noodles) can have very different characteristics.

So far, so good. We have a terrific invention, making useful products that make people’s lives easier and save energy. Remember when you couldn’t get soda in plastic bottles, just glass? Think about how much more fuel it took to haul that extra weight around. Or if you’re older, think about when plastic meant cheap and brittle.

So, what are these molecules, and what’s the problem?

The problem comes about because those little plasticizer or hardener molecules sometimes come out of the plastic and get loose. If you have a vinyl shower curtain, and it’s getting old, take a look at it and you’ll see that it’s still pretty flexible at the top, but the bottom is getting more stiff and crinkly. That’s because the plasticizers are slowly leaching* out as the plastic gets “washed” every day. Where do those plasticizers go? Down the drain, into the sewers, to the waste water treatment plant, and back into the environment. So, someone downstream from me, in maybe Dubuque, or St. Louis or Memphis or New Orleans is drinking coffee made with river water that has a few molecules of my shower curtain in it. (And that’s passed through my kidneys, but that’s another story….)

One of the more common plasticizers is dioctyl phthalate (right). Another substance of concern is the stabilizer Bisphenol A (left). These substances, as they leach out of plastics and into food or water, seem to sort of fit the same places in the body that some hormones do. This causes the systems that depend on those hormones to get confused and not work properly. Because plastics are everywhere and their breakdown products are present in tiny quantities, it’s hard to avoid exposure.

Thanks to the coders who finally fixed the bugs that caused the WordPress iPad app to crash all the time. Working on such a long post would have been incredibly frustrating with the buggy edition.

*pet peeve: homonym abuse. “Leaching” means gradually losing some substance or property; “leeching” means parasitically taking, like the animal does. Misuse homonyms and I’ll disrespect the content of your writing as well as its substance. Also, I wish autocorrect would learn that “its” (possessive) is different from “it’s” (contraction of “it is”). When confused about which it’s to use, it’s best to try substituting its short form for the long form “it is”. It is ridiculous to say, “my car is great, except for it is uncomfortable seats”, so it’s appropriate to use “its uncomfortable seats”, with no apostrophe. That one’s for you, Mom.

It’s not my deFault.

Okay, today’s news is filled with discussions of Republicans suggesting that we don’t actually have to default after October 17th.
Rand Paul says a default is just “balancing the budget” – yeah, by not paying the mortgage!

“It really is irresponsible of the president to try to scare the markets,” said Senator Rand Paul, Republican of Kentucky. “If you don’t raise your debt ceiling, all you’re saying is, ‘We’re going to be balancing our budget.’ So if you put it in those terms, all these scary terms of, ‘Oh my goodness, the world’s going to end’ — if we balance the budget, the world’s going to end? Why don’t we spend what comes in?”
“If you propose it that way,” he said of not raising the debt limit, “the American public will say that sounds like a pretty reasonable idea.”

Well, now some Rs are saying it’s not just about Obamacare but all the deficit and national debt…
So here’s a few numbers to play with.
According to much economic research, there is a correlation between states that mooch off the Federal deficit and states that vote Republican. Slate has an excellent analysis. Now, comparing this data with the election maps shows a pretty clear connection.

Looking at the numbers (2005 is the latest available here), cutting off just the excess payments to the worst ten states (per capita) would save about $125 billion per year. That’s not cutting off all payments, just the excess above what those states pay in federal taxes.

This is a sum greater than the “sequester” cuts, which Republicans would say didn’t hurt anybody.

Unfortunately, a great deal of that excess payment money (Slate, again) is anti-poverty payments. Yes, the poorest states are also the most conservative. Or maybe, the most conservative states are also the poorest – you make the call.
So, do the red-state, tea party types hate spending because it largely flows to the poorest in their communities? Is spending on the poor more visible in the very poor states, and thus an easier target?

Maybe they are actually compassionate, caring people in their own lives. But they don’t seem to be willing to be compassionate to the strangers in their midst.

Here’s another story – this time from The American Conservative (from September 2012) looking at the number of people in each state who don’t pay Federal income tax (the infamous 47%). Turns out, 47% is pretty high. The states with the most “non-payers” have about 40% non-payers; the states with the fewest are around 30%. (Wait, who files a return and has no tax liability? Poor people, mostly, whose deductions outweigh their tax liability. Most of them file to get their withholdings back.)
Again, it’s the poorer, more conservative Deep South states that have the most zero-liability returns. Except for a few Rural West states (ND, WY, AK), most of the highest-liability states are “blue states”.

All in all, I think Albert Alligator explained it best:

Pogo by Walt Kelly, April 14, 1956 found at

This is not an overly coherent post. Busy week. But, some interesting tidbits. I just double-dare Obama to say that debt service comes first, poverty relief second, and any other payments to states, or military bases & contractors located therein, whose senators and/or representatives vote for default get lowest priority.