Valerie Weaver-Zercher has a thoughtful essay in today's Chicago Tribune http://www.chicagotribune.com/news/opinion/ct-perspec-1003-dryer-20101003,0,3250324.story about doing the laundry--without a dryer.
I think she rightly points out that our standards--our expectations, our aesthetics--have to change. We have to learn to accept--embrace?--rough and wrinkled clothing, though I'd add that hygiene is also involved. If you wash in cold water and then air dry, then there is no hot water and no hot air drying to really take on those dirty smelly gym clothes your kids bring home.
A few dimensions deserve more discussion, though:
First, where she lives and does laundry. The by-line indicates she lives in Pennsylvania--which, I can attest from first hand experience, is a great place to hang out clothes many months of the year. But what if she lived in Houston? I have visited that city a handful of times, and wow, is that place humid. It seems to me that clothes would never dry whether you hung them inside or out--unless you used an indoor rack AND TURNED ON THE AIR CONDITIONING--probably not the right idea here. You'd need something to get the humidity out of the air before line drying (as a rule) makes sense. So, first caveat--can't do this everywhere as easily as Pennsylvania. [BTW, my mom still hangs her clothes out in PA!]
Second, wealth. By that I mean, resources (house, land, space, square footage...) and control over how the author spends her day (she could check email in the morning, or she could do laundry and spend her scarce time washing, hanging, and then folding clothes). She is in a great position, with a lot of discretion, and she can make choices. Yes, we all make choices. But what about a family of 3 or 4 living in a 750 square foot apartment in a major city? Overall, it seems likely that the carbon footprint for that family is smaller than that of many who live in single family or simply less dense housing, so it's hard to argue that they should also hang their socks up in their tiny living room. That family has already made choices that seem pretty darn climate-friendly, so I think it's unreasonable to ask them to do more by foregoing use of their dryer.
Maybe one response to the latter concern is to repeat the author's suggestion that we change our expectations about what is good, lovely, tasty, beautiful, and so on. Maybe we need to be content with less--smaller houses and apartments, smaller cars, fewer trips to see friends or family who live far away.
Anyway, it's good to see this issue getting the discussion it deserves.
Sunday, October 3, 2010
Friday, October 9, 2009
Should commuter trains carry defibrillators?
The Chicago Tribune (http://www.chicagotribune.com/health/chi-metra-defibs-09-oct09,0,5601601.story) reported on October 9, 2009, that a commuter suffered a heart attack during his commute the previous day and despite efforts to administer CPR on board the train, the man died. Would an AED (automated external defibrillator) have saved his life? And, policy wise, should Metra and other operators of commuter trains be required to have AEDs aboard?
The article reports that defibrillators cost between $1200 and $2500. Is that a lot of money to spend on reviving a person in cardiac arrest? Of course, posing the question that way is too easy--of course if we see a person in cardiac arrest, we are likely to think we should spend $2500--or $25,000, or $250,000--to provide the medical care needed to take care of that person.
But that isn't the right way to pose that question, because ex post, or after an cardiac incident occurs, we will want to spend whatever it takes to care for the individual. It's a bit like waiting until a house fire breaks out and then asking the homeowner if he is willing to contribute money towards the local fire department. I"m guessing the answer to that one would be "yes."
So what is the right way to pose the question? We need an ex ante approach: we need to say, what is it worth to lower the risk of a certain event happening?
In this case, we can ask, how many lives would be saved if we required AEDs on Metra's commuter trains? What would it cost to install and maintain these AEDs? And is that expense worth paying, given the likely impact on fatalities averted?
Some evidence suggests that AEDs are as cost-effective as many other health interventions:
In the U.S., we often apply a "rule of thumb" in which interventions or treatments that cost less than $50,000 per QALY saved are cost effective, and by that measure, these studies suggest that AEDs meet that standard.
What does that mean for Metra or other operators of commuter trains? Well, the impact of the devices on lives saved will depend in part on how many people ride the train and are at risk of going into cardiac arrest. If a train only carries 10 people all day long, it's hard to believe that installing an AED would be worth it--meaning, the likely effect on averted fatalities (reflecting 10 people, 24 hours a day, having some underlying risk of going into cardiac arrest) would be small, so that the cost per QALY saved is likely pretty high. But if a train carries 1000 people--or 4000 people--or ???? people--all day long, then the number of expected averted deaths will be greater and, consequently, the $ cost of per each gained QALY will be lower.
So, my recommendations would be:
The article reports that defibrillators cost between $1200 and $2500. Is that a lot of money to spend on reviving a person in cardiac arrest? Of course, posing the question that way is too easy--of course if we see a person in cardiac arrest, we are likely to think we should spend $2500--or $25,000, or $250,000--to provide the medical care needed to take care of that person.
But that isn't the right way to pose that question, because ex post, or after an cardiac incident occurs, we will want to spend whatever it takes to care for the individual. It's a bit like waiting until a house fire breaks out and then asking the homeowner if he is willing to contribute money towards the local fire department. I"m guessing the answer to that one would be "yes."
So what is the right way to pose the question? We need an ex ante approach: we need to say, what is it worth to lower the risk of a certain event happening?
In this case, we can ask, how many lives would be saved if we required AEDs on Metra's commuter trains? What would it cost to install and maintain these AEDs? And is that expense worth paying, given the likely impact on fatalities averted?
Some evidence suggests that AEDs are as cost-effective as many other health interventions:
- A somewhat dated (1998) article by Nichol et al. in the journal Circulation (http://www.circ.ahajournals.org/cgi/content/full/97/13/1315 ) offers some evidence that public (lay) use of AED's would be cost effective by "usual" U.S. standards: the authors estimate a median cost of $44,000 per QALY (quality adjusted life year) saved by use of the devices.
- A study of the use of AEDs on commercial aircraft (2001, Groeneveld et. al; http://gateway.nlm.nih.gov/MeetingAbstracts/ma?f=102273455.html ) of AEDs' cost effectiveness found that "Placing AEDs on all passenger aircraft with concurrent BLS [basic life support] training would cost $49,800 per QALY gained compared to no AEDs and no BLS training."
- A more recent study (2009, by Nichol et al., here: http://www.annemergmed.com/article/S0196-0644(09)00101-2/abstract ) estimated a mean cost of $46,700 per QALY saved by use of AEDs by lay responders.
In the U.S., we often apply a "rule of thumb" in which interventions or treatments that cost less than $50,000 per QALY saved are cost effective, and by that measure, these studies suggest that AEDs meet that standard.
What does that mean for Metra or other operators of commuter trains? Well, the impact of the devices on lives saved will depend in part on how many people ride the train and are at risk of going into cardiac arrest. If a train only carries 10 people all day long, it's hard to believe that installing an AED would be worth it--meaning, the likely effect on averted fatalities (reflecting 10 people, 24 hours a day, having some underlying risk of going into cardiac arrest) would be small, so that the cost per QALY saved is likely pretty high. But if a train carries 1000 people--or 4000 people--or ???? people--all day long, then the number of expected averted deaths will be greater and, consequently, the $ cost of per each gained QALY will be lower.
So, my recommendations would be:
- Require Metra to install AEDs on trains that meet some sort of minimum usage standard.
- Allow Metra to recoup the cost of the AEDs through its ticket prices. After all, the beneficiaries of the installation are quite clearly the passengers.
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