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Thank you Lior for the A2A!I would like to see the sort of policing reforms that would result in Americans of all ages, ethnicities, genders and socio-economic backgrounds actually look forward to an interaction with the police.Could you imagine that? Can you actually imagine an America in the 2020s with police that you would actually want to interact with, not fearful of losing your life, liberty or pursuit of happiness?When was the last time you approached a police officer without trepidation that, despite your innocence, things might escalate into an unpleasant encounter? For me, it was the last time I was in France.Because even I — a white, male, retired Air Force lieutenant colonel without a single police infraction on my record — have little trust that an American policeman has the education, training, motivation or organizational culture to be a decent, self-controlled human capable of dealing with a situation calmly and professionally without escalating an issue into an unpleasant or even potentially violent or deadly situation.Believe it or not, I am not writing this answer to shit on the police. Almost no police man or woman — apart from white supremacists or mafia/cartel infiltrators — joins the police to become a thug, a gangster or a criminal. Yet the brutal and ugly police state we Americans have constructed and allowed to develop over the decades has transformed many police departments from embodying “To Protect and Serve” into “Dominating Anyone We Come Into Contact With via Overwhelming Force”. We owe it to our police men and women to liberate them from this degrading and dehumanizing system.Much smarter people than myself have painstakingly chronicled how we got into this mess including Radley Balko in The Rise of the Warrior Cop - Wikipedia. (Cliffs Notes version: Republican politicians adopting ‘Tough on (minority) Crime’ policies in the ‘War Against (some) Drugs’ and dragging reluctant Democrats along with them.) However, I must take exception to the title, because our police do not deserve the title of ‘warriors’ — elite, highly disciplined and professional operators. Instead they are frequently lowest-common-denominator, poorly educated, badly trained, undisciplined paramilitary wannabes. A gang, you might say, or an invading armed force.As a result, every day hundreds of thousands of Americans endure unnecessarily unpleasant and sometimes lethal encounters with police which further erode trust on both sides, leading to an almost unbridgeable Us vs Them chasm.This is the godawful mess we Americans find ourselves in during the miserable year 2020. How do we dig ourselves out of it and establish a police force in which American citizens have trust?Well, I am a firm believer that disciplined habits vastly outperform motivation. Similarly, while personalities come and go, setting up a system so that it encourages and rewards good habits is essential to long-term positive change. Keeping in mind that these reforms are only a small part of a much larger necessary economic and political reform — including the repeal of the ‘War on Terror’, the ‘War on (some) Drugs’ and ‘broken windows policing’ — I humbly offer the following four systemic restructurings:Community Policing - a police force of neighbors you know and trustProfessionalization of Unprofessional Police - mandatory education, training and organization … just like a real professionPolice Health and Wellness - mentally and physically healthy police officersCitizen-based Oversight of the Police - the only path to legitimacyThat probably comes off as a little pie-in-the-sky, so let’s examine specific actions within each of these focus areas where the rubber needs to meet the road.(I’d talk with this guy, just to figure out his wheelie technique.)COMMUNITY POLICINGResidency. All police would be required to live in the actual neighborhood that they police. Not the next county over, not in an adjacent state … the actual neighborhood that they work to maintain the peace in. The police department would provide a housing stipend (similar to the military’s Basic Allowance for Housing or BHA) for areas with high housing prices.Face to Face. To the maximum extent possible police would not patrol from enclosed vehicles, rather they would walk, bicycle or use other non-automotive means to patrol their neighborhood in order to actually meet face-to-face with the people they serve.De-paramilitarize.The vast majority of police would wear a white-colored and non-military style utility uniform similar to Postal Service workers without chevrons, stars or other military-style emblems.Police titles would use non-military terminology instead of ‘officer’, ‘sergeant’, ‘lieutenant’, etc.Most police would not carry lethal weapons and would be required to adhere to the “Absolute Necessity” doctrine for lethal force.Police would divest of paramilitary gear including armored assault vehicles, HUMVEEs, tear gas, pepper bullets, rubber bullets and water cannons.No-knock raids would no longer be conducted as they greatly increase the chances for accidentally wounding or killing innocent people.De-SWAT.The vast majority of SWAT teams would be disbanded unless they could prove their requirement to an independent Justice Department review board. The few deemed essential would not be permitted to take part in any routine, non-SWAT activity policing functions (e.g., enforcing liquor law violations, crowd control, etc).All SWAT teams would have an embedded member of the independent inspector body and an observer from the American Civil Liberties Union and Human Rights Watch participate in all aspects of planning, conducting and reporting on SWAT actions.De-monetize.Police would no longer have power to confiscate money or property through mechanisms such as civil forfeiture, asset forfeiture, etc.Police would be fully funded by taxes and would no longer be able to collect or use money from fines, bail or any other mechanism to enrich their department or themselves.All fines and fees collected by police would be directly deposited into the budget of the independent inspector body.Police would be forbidden to institute or enact quotas (e.g., speeding tickets, arrests, etc).De-Paperwork. Paper report forms would be replaced with an encrypted smartphone app generating easily filled out reports pre-populated with relevant data (e.g., GPS coordinates, date/time, police IDs, etc) with copies accessible to both the police and the independent inspector body (more on this later).Civilian Complaint Review Boards. Legally empowered by the mayor to review police misconduct allegations and make sure that discipline is administered when it occurs. This would combine with:Public Disciplinary Records. Because sunlight is the best disinfectant when restoring the public’s trust in a formerly secretive police force.PROFESSIONALIZATION OF UNPROFESSIONAL POLICEBoard Certification. Police would be required to meet minimum education and training requirements, including continuing education, in order to obtain a license good for 2 years. Only licensed police would be allowed to practice, and the independent inspector body could revoke this license.Background Vetting. Before being hired, police recruits would be thoroughly vetted by an external investigative service that is incentivized to uncover incidences of violent crime, domestic violence, financial wrongdoing, participation in violent extremist political groups (e.g., white supremacy, anti-abortion terrorism, organized crime, etc.) The independent inspector body would also conduct a separate background check of potential police recruits.Personal Liability Insurance. Police would be required, like medical professionals, to obtain and maintain personal liability insurance to settle misconduct lawsuits.Peace Fund. Each police department would be provided with a retirement fund for officers that would be tied to the peaceful versus non-peaceful incident rate for the department as a whole as an incentive to nonviolent policing.Training.Police training would focus on de-escalation, racial/ethnic bias, techniques for peaceful conflict resolution, customer service skills (politeness, attentive listening and smiling), and the importance of building community relations.Police would receive monthly training by professionals in the fields of mental health crisis resolution, conflict negotiation, social work, child advocacy, traffic safety, sexual assault counseling and emergency first aid.National Police Misconduct Database. The independent inspector body would provide information on all police misconduct to a Department of Justice database. Thorough review of this database would be a state requirement for due diligence during police board certification and licensure.Affirmative Intervention. All police would be required to adhere to the doctrine of affirmative intervention when they become aware one or more of their fellow police are abusing their authority. Failure to do so would result in the independent inspector body withdrawing their police license.POLICE HEALTH AND WELLNESSCompetitive Pay. Police salaries would set high enough to be competitive with other well-compensated career fields without the need to chase overtime hours in order to decrease the temptation to supplement pay with graft.Mandatory Physical Fitness. Like the military, police would be required to meet or exceed rigorous standards for physical fitness administered by an external testing agency with no connection to the police department.Mandatory Mental Fitness. Police would regularly participate in counseling sessions with external psychologists with no affiliation with any police department. Those exhibiting elevated mental stress would be rotated out of police work to de-stress and would be provided with mental health counseling until certified as fit for duty.Yoga and Meditation. Police would participate in an hour of yoga at the start of each shift, and the police department would either provide a yoga room with instructor or pay for police to take free yoga classes.Jiu-jitsu. Wait, what? Yes, police would be regularly trained in jiu-jitsu in order to improve their self-confidence, ability to defend themselves in a confrontation, and their knowledge of how restrain a suspect without injuring him or her.USADA-style Testing. Police would be regularly but aperiodically tested by an outside agency with no connection to any police department for abuse of drugs including steroids, testosterone, human growth hormone and other androgenic substances, similar to professional athletes. Those in violation would lose their professional license for six month (1st offense), two years (2nd offense) and lifetime (3rd offense).CITIZEN-BASED OVERSIGHT OF THE POLICEIndependent Inspector Body. Has complete and unfettered access to all police data including databases, communications, police reports, bodycam video/audio. Automatically launches an investigation into any incident of police-caused bodily trauma or death.Body Cameras. Police would be required to wear body cameras during duty hours over which they have no control. Encrypted video feeds would automatically be sent to the independent inspector body and could only be requested on an as-needed basis and by formally documented request from this body by the police department.Chain of Custody. Police would be required to maintain positive control over the evidence chain of evidence for every incident. Lost or tampered evidence would result in an automatic investigation by the independent inspector body.Violent Reports. Every single incident of police use of force would require a report that would be immediately reviewed by the highest ranking members of the department as well as the independent inspector body. Unjustified police use of force, particularly if manifested as a pattern of behavior, would be grounds for loss of their professional license as well as criminal and/or civil charges.Public Disciplinary Reports. As is being enacted in New York City, police disciplinary reports would be made public so citizens would be able to determine whether or not their tax dollars are being well spent on police who are acting professionally.End Grand Juries. Police accused of improper use of deadly force would no longer be tried by secretive grand juries but by independent prosecutors with no connection to the local police.End Police Unions. Just as the military with a monopoly on national-level violence has no unions, police departments with a monopoly on state-, city- and county-level violence should not have unions.End Qualified Immunity. Last but certainly not least, qualified immunity would be scrapped to deny violent rogue police the legal shelter from the consequences of their murderous actions. Hey, it’s just a few bad apples, right? If you have nothing to hide, you have nothing to fear.So there you have it, one citizen’s ideas on steps that can be taken to transform our current police force into actual public servants. Please also read the former President’s Task Force on 21st Century Policing report if you have a spare couple of hours on your hands.Do you think this is an important issue? Then please share it with your friends and family, discuss it with your co-workers and advocate for police reform to your politicians.

My closest friend is a paramedic and I have spent many hours on ride-outs with the Fast Response Vehicles so I'm going to give this a go.Generally speaking, it can be all, or nothing. And there is certainly a case for arguing that 'all human life was there'.She tends to arrive for her shift 30 minutes before the start time, this is so that she can prepare herself mentally but also so that she can check her equipment on the car. This includes a defibrillator, bags containing airway management equipment and cannulation equipment.As a solo (fast) responder, she tends to get sent to cases which are known as 'Category A' - these tend to be the most serious and life threatening. Alerts are sent through to a computer in the car and are signified by an audible alarm, the alarm continues to sound until it is accepted by a push of a button. Satellite navigation guides her to the location. FRV (fast response vehicles) are expected to get to the 'job' within 8 minutes for 'cat A'. Very much pedal to the metal. (all paramedics and ambulance technicians in the UK are 'blue light' trained)On arrival, she again needs to confirm on the computer. The intention is that sole-responders are not sent to jobs where the patient is potentially violent but many slip through the net.Carrying a minimum of two heavy and bulky bags, (the defibrillator, oxygen etc) she needs to make contact with the patient. This can involve a fair amount of walking, often involving stairs. She has to assess the patient and decide whether they need to be transferred to a hospital, if so - she will need to call for back-up from an ambulance. (often to be told that it is 'kilo zero' - meaning no back-up is available) At that point, she has to decide whether to request an immediate or 'hot' response or whether the patient can wait for a 'cold' response. A big responsibility as her decision not only affects this patient but might also affect the time other patients are waiting.She needs to record the patient details on a PRF (patient report form) and has to measure blood pressure, pulse, ECG etc. If necessary, she will cannulate the patient and give any drugs required. (morphine, nebulisers, cardiac drugs etc) She also has to deal with the family and friends of the patient who may be extremely anxious.Calls may be to a patient's home address (and these can vary enormously, stately homes down to flats with needles on the floor from drug addicts)She also has to attend incidents in the 'open'- collapses due to cardiac problems, drink or drugs. She may be required to be first on scene at road accidents (as on two occasions this week), she climbs into badly damaged vehicles, into ditches and under collapsed buildings (again within the past few weeks)She deals with the 'worried well' and the desperately ill. She decides if the patient is well enough to be left at home after giving medical advice (that's the scary bit too) She deals with everyone from newborn babies to patients in their early 100's.Once she has completed the job, she needs to 'call clear'. That means that she is available for another job. And off she goes again. In a 12 hour shift, she will get one break - usually after 9 hours. She is seldom off on time. crews are eligible to be given a 'job' until the precise minute of their finishing time. And they often are. This can mean finishing a shift an hour or more late.Then she comes back to do it again.

Indian pharma companies versus the US FDA and Indian regulators: the story in a nutshell.In the proverbial blink of an eye, soaring US drug costs have driven the shift from branded to generic, from drugs made in the US to those made elsewhere. As much as ~80% of active pharmaceutical ingredients (APIs) and as much as ~40% of finished drug products in the US now come from China or India (1). Not because this is necessarily better for the health of US patients but because generics are much cheaper. The statistics reveal how drug pricing pressure plays out in the US market.Even though generics comprised only ~22% of US drug spending in 2019, they made up ~95% of prescribed medications, which amounted to ~$2 trillion dollars in savings over the past 10 years (1).As production shifted overseas, US regulatory oversight initially didn't keep pace even as local oversight remained lax to non-existent. The FDA didn't initially uncover evidence of outright fraud at overseas drug manufacturing facilities proactively but rather unusually courageous and persistent whistleblowers such as Dinesh Thakur brought it to their attention.In any case, Indian (and Chinese) generics makers have also quickly adjusted to more stringent standards and inspections from the FDA since regulatory laxity at home has allowed them to evolve ways to manufacture drugs that vary in quality depending on the country that buys their drugs, “dual-track”, “multi-tier” or “row A/row B production (2). Who pays the price in terms of lives lost? Why, poorer countries of course, India itself among them, countries that don't insist on safety and quality, countries that gratefully buy whatever drugs come their way, the cheaper the better. In fact, people across Africa have actually died as a result (2).Whistleblowers notwithstanding, such persistent demand for cheaper drugs gives global generic drugmakers powerful leverage to continue as is and they're learning that all too well. After all, what are the alternatives?Bring back US-based drug production? Prices would go up even more when they're already unacceptably high.Stop buying generic drugs made elsewhere and let US patients die? Out of the question.Classic Catch-22. What needs to happen to change this terrible and untenable status quo?The US Congress needs to step up and do its job.Force the FDA to better enforce its regulatory mandate. Not just warning letters and import bans but they also need to start pursuing cases in US courts of law to hold errant companies and their senior executives criminally liable for fraudulent actions. Also make surprise inspections standard in overseas facilities the way they are in the US.Enact laws that set drug price controls.Overseas drug regulators need to start enforcing. That requires dramatic changes on their part as well as broader changes within their civil society,A cultural sea change; Indian drugmakers should fear Indian regulators rather than see them as partners.A mammoth increase in the Indian drug inspection workforce with intensive and thorough training commensurate to their onerous drug enforcement authority (below from 3 and 4).What if Indian investigative journalism also came into its own and began to regularly expose wrongdoing within Indian pharma? Doing so would enable the creation of a virtuous cycle whereby the Indian public would also demand better quality drugs and pressure their government and drugmakers to implement necessary changes.Obviously, all this is a very tall order indeed and, at least at present, seems quite unlikely to come to pass. This is why where Indian pharma companies are concerned, neither the US FDA nor Indian regulators emerge covered in glory.What investigative journalists and whistleblowers have uncovered about Indian generic drugs manufacturing.The stink from regulatory oversight failures became so bad in recent years, the investigative journalist, Katherine Eban - Wikipedia wrote a 2019 New York Times bestseller about it (2). A wild, hair-raising ride into the extremely lucrative but corrupt belly of global generic drug manufacture. For me, the highlights of Eban's recent interview (February 18, 2020) to The Wire's Siddharth Varadarajan - Wikipedia were (my transcript from 5),“Fraud is endemic in the generic drug industry. What if anything is the incentive for quality?...The Indian market has a significant amount of substandard drugs. There is also no question that US patients have gotten substandard generics...The US companies fear the FDA, they fear their regulators and they are subject to surprise inspection. If you are going to be subjected to a surprise inspection and you are fearful of your regulator, you would be more inclined to follow the rules whereas you know all of my reporting here [in India] suggests that companies don't fear the regulator, they see them more as the partner, which I think is very problematic from a public health point of view...The book is highly critical of the US FDA. I mean the 8 years they spent investigating Ranbaxy all the while approving Ranbaxy's drugs, giving them the green light for the biggest generic drug launch in US history, generic Lipitor. Why? …I think the global regulatory system is broken...Ranbaxy...The fraud...is documented in US FDA inspection reports...No individual was ever prosecuted...The company pled guilty to 7 felonies...No criminal prosecution of individual executives and without that, it's very hard to really hold people accountable and to send a message through the industry that this behavior is not accepted...The US FDA...are committed to not creating a public panic, to telling everybody that it's fine and they barely even stop doing that when people are literally falling over dead. I mean with the tainted heparin...they almost never tell people to stop taking their medicine...Dual track production which is that the generic companies make one level of quality for their export markets, to Europe and the US, and they make another level of quality for the rest of the world market, so that would be India, Africa, and unfortunately, they are making just the worst of the worst drugs...(Siddharth Varadarajan: different standards for different markets?)...that is absolutely problematic. I mean, you know, as one executive described it to me, that's almost like a cancer that spreads throughout your organization, if you begin to assume that it's okay to make a substandard drug for one set of humans and a different quality for another set of humans...From what I can observe it's only economic harm to the companies in India that will essentially lead the government to become better regulators. I don't see evidence right now that the Indian regulators feel compelled to act and similarly in the US, the dynamic is there that only the US Congress is going to be able to compel the FDA to change how it regulates. You know regulatory bodies are very sleepy animals and they have to be frightened into working properly. ”Consistent bad press of this nature (6) as well as whistleblower reports over the past few years helped stoke public pressure and finally forced the FDA to step up its vigilance and enforcement practices with respect to the quality of generic drugs being sold in the US. Result is many more FDA warning letters and import alerts to overseas generics drugmakers. Some of the unacceptable issues that forced the FDA to bar some Indian drug makers from shipping drugs to the US included (from 7 drawing on data in 8).“(1) alteration/manipulation of product and air quality data;(2) failure to review consumer complaints and hiding incident reports off site;(3) back dating quality testing;(4) altering/forging clinical trial data;(5) alteration of training records for quality assurance personnel or functions;(6) using data recording methods where data were preliminarily written down but could be overwritten, with the original data lost;(7) presence of unauthorized quality assurance stamps; and(8) performing multiple retesting of deviant samples and only recording the one that passed.”Also (from 7 drawing on data in 9, 10, 11),“(1) shredded documents late at night before an FDA inspection,(2) allowed unsanitary manufacturing conditions, or(3) allowed “uncontrolled use of ‘trial’ injections during chromatographic testing” to achieve passing tests for drug batches or other reporting irregularities.”Nothing new under the sun. Much of this sounds like Theranos redux except that was about regulatory oversight failure over blood tests by a US start-up while this is about Indian generic drug makers. Note also that some of these egregious manufacturing failures were reported to have taken place not just in plants in India but also in the US (10).A long view of where things are at would suggest that we are in the middle of a tumultuous and momentous transition phase as global drug manufacturing shifts from US and Europe to China, India and elsewhere. That necessitates a steep learning curve for all involved. With human life at stake, manufacturing drugs has nothing in common with making cheap, throwaway widgets and gadgets. That the learning is thorough and beneficial for public health depends more on the actions of lawmakers and regulators and less on drugmakers. The Hindi proverb, “jiski lathi uski bhains” (who holds the stick, owns the buffalo) comes to mind. As long as drugmakers wield the stick, i.e., they get away with a mere slap on the wrist, outcomes will continue to be in favor of company profits over product quality.Bibliography1. 2019 Generic Drug and Biosimilars Access & Savings in the U.S. Report2. Amazon.com: Bottle of Lies: The Inside Story of the Generic Drug Boom (9780062338785): Katherine Eban: Books3. If I follow US standards, I will have to shut almost all drug facilities: G N Singh4. Kadam, Abhay B., et al. "Correcting India’s chronic shortage of drug inspectors to ensure the production and distribution of safe, high-quality medicines." International journal of health policy and management 5.9 (2016): 535. Correcting India’s Chronic Shortage of Drug Inspectors to Ensure the Production and Distribution of Safe, High-Quality Medicines5. Watch | Katherine Eban Interview: How Drug Makers Are Compromising the Lives of People6. Eban, Katherine. "Dirty medicine." Fortune Magazine (2013). https://rauhpsychiatry.com/wp-content/uploads/2017/04/Dirty-medicine-Fortune-Features-copy-4.pdf7. White, C. Michael. "Generic Drugs Not as Safe as FDA Wants You to Believe." (2019): 1060028019881692. Generic Drugs Not as Safe as FDA Wants You to Believe - C. Michael White, 20208. FDA Form 483s From India: A Deep Dive Into the Problems9. Hetero Labs plant hit with Form 483 for suspicious shredding of documents10. http://10.https://www.fiercepharma.com/manufacturing/wockhardt-u-s-plant-nailed-by-fda-a-warning-letter11. US FDA flags issues at Sun Pharma’s Halol plantThanks for the R2A, Kritika Gupta.