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6 | THURSDAY, AUGUST 8, 2019 THE NEW YORK TIMES INTERNATIONAL EDITION
world
They avoid main roads. They maintain
good posture. Sometimes they choose
not to drive at all.
For years, some black drivers in the
St. Louis area have taken those precau-
tions to avoid getting pulled over by the
police. And yet it has not seemed to pre-
vent them from getting stopped, tick-
eted and fined at higher rates than peo-
ple of other races.
After a police officer killed an un-
armed black teenager named Michael
Brown five years ago in Ferguson, Mo.,
protests there rocked the United States,
leading to a public outcry over race and
policing. People were outraged to learn
that municipalities throughout St. Louis
County had been issuing traffic tickets
to finance city services — and jailing
drivers who could not afford to pay —
with black residents bearing the brunt
of those policies.
Five years later, black drivers contin-
ue to be stopped at much higher rates
than white drivers, a disparity that has
actually grown in Ferguson despite
changes — including a new state law —
that have greatly reduced the number of
traffic tickets, fines and arrest warrants
issued.
Statewide, black motorists were
nearly twice as likely as other motorists
to be stopped, based on their share of the
driving-age population, according to the
Missouri attorney general’s annual re-
port on traffic stops. White drivers were
stopped 6 percent less than would be ex-
pected. In Ferguson, the disparity in
traffic stops of black drivers has in-
creased, the report indicated.
“I can’t say things have gotten better,”
said Blake Strode, the executive direc-
tor of ArchCity Defenders, a legal advo-
cacy organization that has fought unfair
ticketing practices. “I understand the
status quo to be one of structural racism,
poverty, overinvestment in the carceral
system, and policing and prosecution.
That is as real today in 2019 as it was five
years ago in 2014.”
Jason Armstrong, who became Fer-
guson’s police chief last month after
serving at a department in suburban At-
lanta, said the data might not tell the en-
tire story, noting that the disparities
grew in Ferguson even as the depart-
ment transformed from being largely
white to more than half black. Since Mr.
Brown’s death, the number of black offi-
cers in the Ferguson department has
skyrocketed to 21 from four.
“At the end of the day, how are people
being treated,” Chief Armstrong said.
“Does the officer treat you like you are a
mother, a father, a brother, a sister, a hus-
band, a wife? Do they treat you profes-
sionally? That’s the biggest part of it to
me.”
While traffic courts in the region may
be less crowded than they were several
years ago, the makeup of the drivers
looks largely the same.
During a traffic court session in Fer-
guson in mid-July, the line stretched out
the door. Although the city is two-thirds
black, almost everyone appearing be-
fore the judge that day was black. Afri-
can-Americans also accounted for the
overwhelming majority of drivers ap-
pearing in traffic courts recently in the
nearby towns of Florissant and St. Ann
— both of which have predominantly
white populations.
In Ferguson, the dreary routine of
traffic court played out over two and a
half hours — 90 minutes longer than was
scheduled. People filed through a metal
detector and had to store their cell-
phones in manila envelopes to take
them into the courtroom.
As a black man driving a 2000 Lexus
LS 400 with tinted windows, De’Shaun
Bunch said he was a prime target. He
said he had been pulled over about eight
times in different municipalities in St.
Louis County over the course of two
years and was in court in Ferguson re-
cently for tickets he had received for
speeding and driving without insur-
ance.
“I’m a black man and I’m driving a
nice car,” he said. “It’s the same. They
were doing it before, they’re still doing it
now. It ain’t changed since Mike Brown
died.”
Mr. Bunch, who works in a shipping
and receiving warehouse, said he had
skipped previous court dates. He finally
decided to show up after getting stopped
about a month earlier. There had been a
warrant for his arrest because of the de-
linquent tickets. In the past, he very
likely would have been thrown in jail.
But Mr. Bunch said the officer simply
took him to a nearby police station,
booked and released him, and told him
to go to court.
While that was a better outcome than
having to spend time behind bars, Mr.
Bunch said the underlying racial dy-
namics of driving while black in St. Lou-
is remained the same as they have for
years. When he is pulled over, officers
sometimes do not cite a violation for
stopping him, he said.
Law enforcement officials in Missouri
have argued that black drivers were
pulled over at higher rates because they
accounted for most of the drivers pass-
ing through particular communities.
But this was the first year that the
state’s report also analyzed instances in
which officers pulled people over in the
communities in which they resided.
Black drivers were still pulled over at
higher rates in many places, including
Ferguson.
“The overwhelming majority of the
pull-overs that I’ve made in my career, I
didn’t know who the person was that
was driving the car,” Chief Armstrong
said. “Do I believe that there are some
officers in this country that may see
somebody that they don’t like and pull
them over for that? Absolutely. But I
think that’s more of the anomaly.”
In an effort to curb excessive ticket-
ing, state lawmakers passed Senate Bill
5 with broad bipartisan support in 2015.
The law capped the percentage of reve-
nue that municipalities were allowed to
earn from their courts at 20 percent,
among other things.
The results have been stark. Munici-
pal courts statewide collected $60.5 mil-
lion in fines last year, a 45 percent de-
crease from 2013. The number of war-
rants issued statewide fell by 18 percent
to 545,484 over the same period.
One of the champions of the bill in the
Senate was Eric Schmitt, a Republican
who is now the state’s attorney general.
In his new role, Mr. Schmitt has at-
tempted to go after municipalities in
court. Last month, he reached a settle-
ment with the city of Diamond, in south-
western Missouri, to end its traffic ticket
quota.
Yet these changes were not enough to
prevent Kylie Malveaux from choosing
to give up driving altogether out of fear
that she might amass more tickets and
fines on top of what she already owed.
She left traffic court in Florissant last
month with $230 worth of unpaid fines.
She also was in danger of getting her li-
cense suspended because of several
other tickets, and had hopes of hiring a
lawyer to help her avoid that outcome.
Ms. Malveaux, 24, now leaves most of
the driving to her partner, Akil Poynter,
25, who was also in Florissant traffic
court last month for driving with a sus-
pended license and a broken taillight.
Both of them needed to return on a later
date to settle their tickets. They seemed
to take the hassle in stride.
“It’s something you get used to,” Mr.
Poynter said.
“It’s terrible that you’re used to it,”
Ms. Malveaux added. “At the end of the
day, you can’t tell a cop who to pull over
and who not to pull over. They have the
freedom to do whatever.”
Stopped, ticketed, fined: Driving while black
FERGUSON, MO.
African-Americans pulled
over more frequently in
Missouri despite new law
BY JOHN ELIGON
De’Shaun Bunch, above, said he has been pulled over eight times in different municipalities in St. Louis County in Missouri over two
years. Left, the new Ferguson, Mo., police chief, Jason Armstrong, said the latest report on traffic stops may not tell the entire story.
WHITNEY CURTIS FOR THE NEW YORK TIMES
JARED SOARES FOR THE NEW YORK TIMES
The killing of an unarmed black
teenager by a police officer five
years ago in Ferguson, Mo., led to
an outcry over race and policing.
In hospitals around the world, the
snakelike duodenoscope is regarded as
an indispensable tool for diagnosing and
treating diseases of the pancreas and
bile ducts.
But these fiber-optic devices have a
remarkable drawback: Although they
are inserted into the upper part of the
small intestine through the mouth and
constantly reused, they cannot be steril-
ized by the usual methods.
Instead, they are hand-scrubbed and
then put through dishwasher-like ma-
chines that use chemicals to kill micro-
organisms. Even when cleaned as in-
structed, the devices may still retain
bacteria that can be transmitted to pa-
tients.
As a result, duodenoscopes have sick-
ened hundreds of patients in hospitals in
the United States and Europe. Recent
testing now suggests regulators se-
verely underestimated the risks. Worse,
the devices have been shown to be capa-
ble of transmitting antibiotic-resistant
infections that are almost impossible to
cure.
Alarmed medical experts are urging
the United States Food and Drug Ad-
ministration to force the manufacturers
to develop scopes that can be properly
sterilized — or to take all duodeno-
scopes off the market.
“The infection data are overwhelming
and irrefutable, and the need is urgent,”
William A. Rutala, the director of the
statewide program for infection control
and epidemiology at the University of
North Carolina, said in an email.
Recent tests performed by the manu-
facturers at the demand of the F.D.A.
found that one in 20 duodenoscopes re-
tained disease-causing microbes like E.
coli even after proper cleaning.
Dr. Jeff Shuren, the director of the
F.D.A.’s Center for Devices and Radio-
logical Health, suggested the agency
may take additional regulatory action.
“Improvements are necessary,” he said
in a statement in April. No action has yet
been taken, however.
HIDDEN DEFECTS
Duodenoscopes are long, flexible tubes
with a fiber-optic camera at one end.
The tube is inserted through the pa-
tient’s mouth and stomach, then into the
first part of the small intestine, called
the duodenum.
The procedure, called endoscopic
retrograde cholangiopancreatography,
is used to diagnose and treat diseases of
the pancreas, bile duct and gallbladder,
such as life-threatening jaundice, tu-
mors, blocked bile ducts and stones.
More than half a million such pro-
cedures are performed each year in the
United States.
The alternative is open surgery,
which carries its own risks, said Dr. Bret
Petersen, a gastroenterologist at the
Mayo Clinic in Rochester, Minn. “Taking
a gallstone out surgically would be al-
most unheard of today,” he said.
But the inability to properly clean the
instrument between patients has
proved to be its “Achilles heel,” he add-
ed. The devices cannot be exposed to
high heat to be sterilized, as many in-
struments are.
It is difficult to clean the narrow inner
tubing by hand, and duodenoscopes, un-
like other endoscopes, have a movable
elevator-like mechanism at the tip that
can be manipulated to adjust the posi-
tion of surgical instruments.
The mechanism makes the scope
more versatile, but also more difficult to
clean, as it contains microscopic crev-
ices where bodily fluids and bacteria can
lodge.
Olympus Medical Systems, Pentax of
America and Fujifilm Medical Systems
USA manufacture most of the duodeno-
scopes in use in the United States, with
the lion’s share made by Olympus. Until
recent hospital outbreaks, the F.D.A.
had never asked to review manufactur-
ers’ data about cleaning the complex in-
struments.
The agency allows many medical de-
vices onto the market without subject-
ing them to the kind of safety and effec-
tiveness testing required for new drugs
if the devices are deemed “substantially
equivalent” to a medical device already
on the market. It is the manufacturer’s
responsibility to make sure the new de-
vice works properly — and that it can be
properly cleaned between uses.
The manufacturers claim that as long
as health facilities clean and disinfect
the devices according to the instruc-
tions — a complicated process that can
involve more than 100 steps — duodeno-
scopes are safe for patients.
The instructions also say devices
should be returned to the manufacturer
once a year for service and mainte-
nance.
Since 2012, however, hundreds of pa-
tients in the United States and Europe
have been infected in dozens of out-
breaks linked to contaminated duodeno-
scopes. Among the infectious agents is
carbapenem-resistant Enterobacteri-
aceae, bacteria that do not respond to a
powerful class of antibiotics. The infec-
tion has a 50 percent mortality rate.
More than 30 patients in Seattle were
infected with resistant strains of bacte-
ria such as C.R.E. by duodenoscopes be-
tween 2012 and 2014, and 11 died, though
many were already critically ill. Dozens
of patients at a Park Ridge, Ill., hospital
were infected with C.R.E. in 2013.
In 2015, two patients died and five
were sickened after being infected with
C.R.E. during procedures involving duo-
denoscopes at the Ronald Reagan
U.C.L.A. Medical Center in Los Angeles.
An F.D.A. advisory panel called for
sterilization of duodenoscopes four
years ago, when the outbreaks first
came to light. Today, steam heat — the
gold standard for cleaning and steriliza-
tion — can still damage the scopes, cre-
ating cracks where bacteria can lodge
and necessitating more frequent re-
placements.
In February 2015, the F.D.A. asked
manufacturers to analyze the contami-
nation rates of their devices. But so far,
manufacturers have only completed
about 60 percent of the required sam-
pling. One of the smaller companies has
only completed 15 percent of the re-
quired tests.
SINGLE-USE SCOPES
The flurry of infection outbreaks puts
patients, hospitals and health care
providers in a quandary.
Modern medicine relies extensively
on duodenoscopes and other flexible tu-
bular “scopes” with cameras at the tips
— including bronchoscopes to check the
lungs, and colonoscopes to screen for co-
lon cancer — to diagnose and treat dis-
eases without surgery.
Alternatives to scoping are limited
and include substitute medical tests and
procedures, like stool tests that screen
for colon cancer in lieu of colonoscopies.
(Scopes used for colon cancer screening
are considered much less risky, howev-
er, since they are used in a part of the
body already teeming with bacteria.)
New low-temperature sterilization
technologies may make it possible to
disinfect scopes more effectively. And it
is possible to make disposable scopes
that could be discarded after one use.
Single-use bronchoscopes already
are making their way to market, al-
though they are not expected to replace
reusable scopes. But there is no dispos-
able duodenoscope.
The rising prevalence of superbugs —
life-threatening germs that are resistant
to powerful antibiotics — has height-
ened the sense of urgency.
“As long as organisms were suscepti-
ble to antibiotics, there really wasn’t a
problem, because even if the scopes
were transmitting bacteria, you give pa-
tients antibiotics prophylactically be-
fore and after procedures, and you take
care of it,” said Larry Muscarella, a
health care consultant who scours medi-
cal device reports submitted to the
F.D.A. and has often been the first to
identify infection risks.
But prophylactic antibiotics no longer
guarantee protection. A rise in antibi-
otic-resistant infections worldwide is
nearing a crisis point: The persistent
misuse and overuse of antibiotics in peo-
ple, plants and farm animals has led to
the proliferation of bacteria that resist
treatment to most available antibiotics.
The World Health Organization has
called the growth in antibiotic-resistant
disease one of the most significant
threats to global health. The design of
duodenoscopes makes them particu-
larly susceptible to harboring these and
other bacteria.
But the risk to any given patient is
small, and duodenoscopes are not sig-
nificant factors in the rise of drug-resist-
ant bacteria, said Dr. Alexander J.
Kallen, an epidemiologist at the Centers
for Disease Control and Prevention.
“It’s more of a public health concern
than a concern for the individual pa-
tient,” he said. “The majority of people
who get exposed to a scope contami-
nated with bacteria don’t suffer an ad-
verse consequence.”
“For most patients, it’s a risk they
should absolutely be aware of,” Dr.
Kallen added. “But in most situations
the benefits of the procedure probably
outweigh the risks of an adverse event.”
Ambu, a Danish company, is already
marketing a disposable bronchoscope,
officials said. The company also is test-
ing a disposable colonoscope. It antici-
pates having additional endoscopes —
including a disposable duodenoscope —
on the market in the United States by
2020.
Major drawback for a medical device: It can’t be sterilized
BY RONI CARYN RABIN
The tip of the snakelike duodenoscope is hard to clean. Right, officials at the Ronald Reagan U.C.L.A. Medical Center in 2015. Two
patients died and five were sickened after being infected with resistant strains of bacteria during procedures using duodenoscopes.
SCIENCE SOURCE DAMIAN DOVARGANES/ASSOCIATED PRESS
The use of a fiber-optic tool has
sickened hundreds in the United
States and Europe, raising
concern among health officials.
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