Broken Market

So here we sit, in bed by candle light as the electricity is out. A perfect opportunity for blogging! To our left a generator buzzes and lights blare. To our right a generator buzzes and lights blare. One of the beauties of living somewhere with power outages is to enjoy the quiet darkness. Unfortunately we get all the bad--no hot water, no cooking, no lights--and none of the good--the neighbors are blazing away with loads of noise and light.

Self pity aside, this raises an interesting example of a broken marketplace. Those with money who consume the most electricity have generators so they do not feel the ill effects of the underdeveloped grid and insufficient production capacity. In turn, that means the normal market forces--consumers wanting better service--does not take full effect, as those with the biggest microphones (the rich) do not exert pressure for improvement.

Compounding the problem is that the electrical utility protects certain areas of the city where the richest and most politically influential residents live. If you live in Areas 3, 11, and 12, for example, you experience far fewer outages than in the middle and lower class Malawians neighborhoods.

So, for those of you who are pure market capitalists, I give you Exhibit A in a long list of possible examples where the market fails.

PS As I typed this, the lights came back on. Thought you should know.

Noise Pollution

There is an ongoing debate with many of my urban-loving friends about life in cities. They say cities are full of action: culture, restaurants, people, events! I say cities are full of negatives: concentrated pollution, crowds, noise! Plus, you get the benefits of a city with a simple visit and return home. Anyhow, it is a never-ending debate because, really, we're both right.

That aside, my time in Lilongwe and Malawi in general has highlighted two things: crowds and noise pollution. Malawi is one of the most densely populated countries in Africa and it shows: there are people everywhere. Walk down the street: people. Go to the market: people. Climb a mountain: people! Today while taking Bay for a walk through corn and soy fields: people, people, people! 

To what does this lead? Noise pollution. Cars on the road with horns honking. Music from stereos. People chatting on phones and haggling on prices. Construction workers constructing. Generators generating. I rarely find myself without some combination of human noises. Finally, today, while wandering about the aforementioned corn and soy fields I found something: quiet. It was beautiful. Birds chirping and breeze through the grass was all that filled my ears. My city-dwelling friends should try it some time.

Doggy Training Classes

 Remember when Bay jumped through a window? He's been much better behaved since then (other than the hoarding). But on Saturday we took him to the vet to make sure that some itchy patches on his skin were benign (they were) and also took advantage of the doggy training classes that are put on by the LSPCA on Saturday mornings. Bay got to be the example dog for heeling (see above). He didn't exactly rock it but he definitely wasn't the worst dog out there. He gets a little anxious around all the other dogs which makes me wonder how he ever survived at the LSPCA for a year and a half.

While Zach worked with Bay and the teacher I took a stroll to see the other dogs awaiting adoption. Look at this cute little female one. Sad.

Places We Go: The Living Room

 Ahhhh the weekend. On Friday night we booked our tickets for a vacation over Easter weekend (details coming soon) before heading to The Living Room for a birthday party. The Living Room is a new restaurant and bar in Lilongwe. The party was loud and crowded so we quickly exited in favor of spending a few hours at the casino here in town which is named 'American Pirates.' Neither of us are gamblers (at all) but we have friends here who make it fun to play blackjack for a few hours and the buy-in is only 300 kwacha per hand (385 kwacha = $1 right now). We won 5,500 kwacha, whoop whoop!

Since The Living Room also serves delicious iced tea and veggie quesadillas we headed back for lunch on Saturday. The outside porch is comfy and breezy and perfect for the gorgeous sunny days we've been having recently. Afterward Zach played in a soccer game at the local stadium (they won), we got dinner at our favorite Indian place with some friends visiting from Lusaka and then went to a birthday party with delicious funfetti cake from America.

Any guesses about where we booked our vacation for?

Dogblogging: Found This Week in Bay's Bed

Tuesday: Vegetables
Thursday: Money (I snatched it away from him before taking a picture because...it's money)

Getting Malaria

Malaria is endemic in Malawi but Zach and I don't take any prophylaxis. Crazy? I don't think so. We live in the city next to good medical care and with quick access to rapid diagnostic tests, unlike many people living in malaria zones. So for us it's a better option to risk that we'll get malaria and get treated quickly than to be sure that we'll rot our insides with a year of malaria prophylaxis. Of course, things are a little more complicated than that but that's the gist of it. However, not being on prophylaxis means that I force Zach to get a malaria test every time he runs a fever - and quickly.

As you can tell, Zach got sick last weekend and had the pleasure of receiving a malaria test while laying in his own bed. There's a benefit to being on the same team as the malaria guy at work - he has a stock of RDTs and knows how to use them. Unfortunately the test doesn't have a spring loaded finger prick so Cary had to just smash the needle into Zach's finger (ouch!). We got some blood on the sheets after three attempts at a hard enough prick. The test came back negative, in case you're wondering. Zach was feeling better the next day and is now completely recovered.

Curing AIDS?

This week a little girl who appears to have been 'cured' of HIV made a lot of news around the world. If you haven't had a chance, check out the story at NPR here. She's only the second human in the world to enjoy the title 'Cured of HIV.' I like that the last one, The Berlin Patient, was a rich old white dude and this one is young, likely of a low socio-economic class considering her mom's behavior, and who knows what race. Maybe God is balancing out his favors.

But what does this actually mean for normal people? It means little but it should be appreciated for what it is: an extraordinary occurrence that shows us how little we know about diseases. It's not a far leap from there to being optimistic that if we know so little there is still so much to learn and so much opportunity for what we learn to completely change the way we treat people living with HIV.

I am incredibly skeptical about this natural experiment ever being replicated on a large scale. Afterall, her mother first infected her with HIV without knowing herself she was positive (rare in the USA) and then stopped giving the infant the ARVs that were sustaining her life (incredibly shitty parenting). These sorts of things do happen naturally but can we identify those situations? Manufacturing that kind of situation is out of the question.

Anyway, the Berlin Patient still appears to be cured of HIV so he and this baby do offer a lot of hope. I just doubt that either of them actually holds the key to the cure. Though I clearly hope to be dead wrong. And I hope they end up being friends, which sounds like fodder for an awesome documentary or book.

Dogblogging: Hoarding Continues

In the latest installment of my series of pictures of Bay hoarding things in his bed, I present to you: Bay and the Dirty Kitchen Rug. This thing is filthy and Zach just can't keep him away from it. So gross to find it's been dragged into our bedroom yet again.

Living in the Matrix

One thing I've come to hate about living in America is that to me it feels like living in a bubble. A soft, comfortable bubble which I adore but a bubble none the less. The simple truth is that life in America is not actually life on Earth. No one else lives the way we do. In fact, 90% of the world doesn't even live *close* to the way we live and yet we go about our daily lives feeling like we're just one of the crew here on Earth. Thinking about how different life is everywhere else is mind boggling. Living in America is like choosing to live in The Matrix. I can understand why most of us want to do it - I want to do it soon! - but remember how you're not actually living on the Earth that everyone else is experiencing or else you're shitting yourself every day. America is not real life on this planet.

To that end, this giant format-busting map from The Red Cross illustrates how Americans live in a false reality where they think Hurricane Sandy was the biggest thing to hit this year. 99% of you never even had the CHANCE to hear about these other occurrences because your normal news outlets didn't cover them. How incredibly odd to not even have access to the truth.

But yes, I'm still planning to come home, drink bubble tea, enjoy electricity, public parks, and festivals. I do love America anyway.

Changing the Game

One cool thing about working in Malawi is that I get to see close-up some game changing initiatives. Malawi's government, despite it's many flaws, is flexible and willing to ditch the status quo when it comes to attempting to improve health outcomes. This even earned us a shout out in Bill Clinton's speech at 2012's International AIDS Society Conference in Washington, DC.

The most material change in policy (for me and my job) has been the implementation of Option B+. Here in Malawi all pregnant women are initiated on ART, no matter how close to developing AIDS they may be. If you're pregnant then you're on treatment - for the rest of your life. In other countries you must wait to be very close to developing AIDS before starting treatment (how close depends on which country you live in; you won't be surprised to know that you will start treatment in the US much more quickly than in other countries). Clearly there are drawbacks and benefits and I personally believe that the evidence supports Option B+. And I'm proud of Malawi for being the first to roll out a really ambitious policy.

Malawi made the NPR blog yesterday. It does a good job of explaining the policy for people who don't care about the details but who still want to understand something that affects so many people in sub-Saharan Africa. That is available here, or see text below.

There's great enthusiasm among some global health leaders about a bold – some say radical — strategy to prevent pregnant women from transmitting HIV to their newborns.

But skeptics worry that the approach, dubbed Option B+, will pit pregnant women with HIV against others infected with the virus, diverting resources from the broader struggle against the pandemic.
The goal of Option B+ is to make serious inroads in reducing a stubborn and heart-breaking problem. Every year about 300,000 babies in sub-Saharan Africa are born with HIV.

The new strategy aims to put every pregnant woman with HIV on triple-drug treatment and keep her on it for the rest of her life — even if the virus has not yet damaged her immune system to the point where she needs medications to preserve her own health.

Universal treatment of HIV-positive pregnant women avoids the need to do expensive and often hard-to-access testing of a woman's level of CD4 immune cells to determine if she's sick enough to need long-term antiretroviral drugs.


The name Option B+ distinguishes the strategy from two earlier approaches, called A and B, which have failed so far to eliminate mother-to-child transmission of HIV in most-affected countries. Those other options either reserve triple-drug treatment for pregnant women with severely compromised immune systems or provide it only temporarily around the time of childbirth to those whose immunity is still relatively robust.

A report, published Thursday by scientists at the Centers for Disease Control and Prevention, finds that when Malawi, a small country in southeast Africa, made a big push to implement Option B+, the payoff was impressive: a sevenfold increase in the number of pregnant and breast-feeding women starting anti-HIV treatment in only a year.

"I think this is actually a big deal," CDC director Dr. Thomas Frieden tells Shots. He says the results not only demonstrate that it's possible to implement Option B+ across an entire country, "but that it makes a huge difference. The data are really remarkable."
In the space of about a year, Malawi trained 5,000 health care workers to give Option B+. It doubled clinics offering triple-drug treatment and went from having less than 1,300 pregnant women on HIV treatment to nearly 11,000.

Frieden estimates Option B+ prevented 7,000 infants from getting HIV from their mothers in its first year of operation.

"I think Option B+ is absolutely crucial," Frieden says, "because it gets to people who account for 60 percent of new HIV infections – women of childbearing age."

He predicts Option B+ will have ripple effects that benefit families and communities by sharply reducing transmission of HIV from women to their uninfected partners.

But not everyone is convinced. Among them is Dr. Hoosen Coovadia, a leading South African HIV specialist, who chaired the International AIDS Conference in 2000, which helped focus the world's attention on the pandemic's staggering toll in Africa.

Coovadia tells Shots that he had "a gut reaction" against Option B+ last July "because of the way it was presented" at the International AIDS Conference in Washington, D.C.

"It looked like everyone had been tutored to say this was a great thing," he says. "Hillary Clinton mentioned it in her speech. Almost everyone spoke about B+ as though it was going to change the direction of the AIDS epidemic. But it didn't look to me that there had been adequate consultation. This was a pet program of the U.S. government."

After the Washington conference, Coovadia says he and his colleagues debated the strategy back in South Africa. Recently he coauthored a sharply worded commentary in The Lancet calling Option B+ "extreme."

"The strong push for countries to switch to B+ is premature," they write. "A switch now would be dangerous, ignoring severe ethical, safety, feasibility and economic concerns."
The CDC's report on Option B+ in Malawi this week "is not a convincing argument that B+ is worth all the potential problems," Coovadia says.

South Africa, he says, has been able to lower the rate of mother-to-child HIV transmission from 33 percent to less than 3 percent by treating pregnant women with simpler, cheaper regimens and reserving triple-drug treatment for those who need it.

One big concern is that Option B+ will create tensions in households and communities when it becomes known that pregnant women with HIV are preferentially getting triple-drug therapy whatever their immune status, while other infected people with deteriorating health may not.
"South Africais already a fractious community," Coovadia says. "If it got out that of two women with the same CD4 count, one was treated and the other was not, the scope for tensions would be great."
Frieden's response to that: "Why should being pregnant get you to the front of the line? The answer to that, I think, is first, that it's more likely to get the baby protected ... It also saves the lives of the mother, the child, the family and it stops the spread of HIV."

And the critics? "Frankly, I think they're mistaken," Frieden says.

Coovadia calls for more study of Option B+ before implementing it aggressively. More data will be forthcoming. Rwanda and Haiti have already adopted the strategy, and seven other sub-Saharan countries are actively implementing it or preparing to.