I just got word that one of the papers that I’ve been working on with the Clinton Foundation and the UM Business School has been officially published in Malaria Journal. We’ve been working on a project assessing the impact of supply side drug subsidies on the availability of malaria medications in Tanzania.
This is good!
Trends in availability and prices of subsidized ACT over the first year of the AMFm: evidence from remote regions of Tanzania
Prashant Yadav, Jessica L Cohen, Sarah Alphs, Jean Arkedis, Peter S. Larson, Julius Massaga and Oliver Sabot
Malaria Journal 2012, 11:299 doi:10.1186/1475-2875-11-299
Published: 28 August 2012
BackgroundThe Affordable Medicines Facility for malaria (AMFm) is a pilot supra-national subsidy program that aims to increase access and affordability of artemisinin combination therapy (ACT) in public sector clinics and private retail shops. It is unclear to what extent the AMFm model will translate into wide scale availability and price reductions in ACT, particularly for rural, remote areas where disparities in access to medicines often exist. This study is the first to rigorously examine the availability and price of subsidized ACT during the first year of the AMFm, measured through retail audits in remote regions of Tanzania.
Periodic retail audits of Accredited Drug Dispensing Outlets (ADDOs) were conducted in two remote regions of Tanzania (Mtwara and Rukwa). Temporal and spatial variation in ACT availability and pricing were explored. A composite measure of ADDO remoteness, using variables, such as distance to suppliers and towns, altitude and population density, was used to explore whether ACT availability and price vary systematically with remoteness.
Between February 2011 and January 2012, the fraction of ADDOs stocking AMFm-ACT increased from 25% to 88% in Mtwara and from 3% to 62% in Rukwa. Availability was widespread, though dispersion throughout the region was achieved more quickly in Mtwara. No significant relationship was found between ACT availability and remoteness. Adult doses of AMFm-ACT were much more widely available than any other age/weight band. Average prices fell from 1529 TZS (1.03 USD) to 1272 TZS (0.81 USD) over the study period, with significantly higher prices in Rukwa. The government recommended retail price for AMFm- ACT is 1,000 TZS ($0.64 USD). The median retail ACT price in the final round of data collection was 1,000 TZS.
The AMFm led to large increases in availability of low priced ACT in Tanzania, with no significant variation in availability based on remoteness. Availability did remain lower and prices remained higher in Rukwa, which is a more remote region overall. Low availability of child and adolescent ACT doses could be due in part to lower quantities of non-adult packs imported into Tanzania. Future research will explore whether increased availability and affordability persists and whether it translates into higher ACT use in Tanzania.
Music has taken me to 48 of the 50 states and multiple trips around the country, through Canada, Europe and from end to end of Japan. Music has taken me to just about every ghetto in the United States, into nearly every small music venue and numerous camping areas west of the Mississippi. Very unfortunately, being in a band doesn’t afford one the time to actually see these places, but I can say that I’ve been there.
A touring band’s life is this:
1) Wake up
2) Drive 8+ hours
3) Arrive to venue at 6
4) Unload 1000 pounds of black boxes
5) Wait 7 hours until showtime (while praying that the venue has free food)
6) Play show
7) Rush off the stage to sell things
8) Fight with venue for payment
9) Pack 1000 pounds of black boxes
10) Sleep somewhere
Being in a band was the hardest job I ever had in every respect. It was physically, mentally and spiritually taxing. Imagine have to be a truck driver all day, every day, be an Olympic runner at night, and a commissioned salesman 24 hours a day. This between breaks of moving lots of heavy stuff, trying not to fuck your songs up, and getting paid less than minimum wage for everything. Despite all that, I loved being in a band and very often miss it.
We have not played a show since 2006. In fact, neither of us have played at ALL since 2006. My fingers still hurt. However, as a favor to our friend Mark Maynard, who very sincerely asked us to, we are helping to celebrate the markmaynard.com 10 year anniversary at Woodruff’s in Ypsilanti on Saturday, September 8th.
Please come and see us if you can. We’re very excited to have the opportunity to play again. As there probably won’t be a second time (until Mark’s 20 year anniversary), this is your only chance. We sound better than ever.
(I’m not sure that I’ll have Mark play at the Freewheel Burning 10 year anniversary party, but I’m considering it. Perhaps we’ll ask him to do a Ski Troop Attack reunion.)
Senatorial Candidate Akin’s recent claims that doctors informed him of a magical mechanism by which women can prevent successful insemination were completely unsurprising. The public, particularly in an election season, have little time for detailed analysis of claims and evidence supporting said claims, preferring passionate leaders who make grand assertions. After all, religion makes a cottage industry out of it. Americans don’t much care about the story, but they love a good performer.
Akin’s fantastical claims may be unsurprising, but equally disturbing, particularly to a person who makes his living collecting data and methodically testing claims.
I like his idea, though. The logical outcome of Akin’s claim is that arguments over birth control are moot. Women have the mechanism to stop reproduction. We no longer need pharmaceutical birth control and abortion. Perhaps the ladies are just lazy.
Fantastic notions of the mysteries of reproduction, are not new. For example, Edward Clarke, a 19th century Harvard professor, once claimed that providing education to women would result in enlarged brains, thus atrophying the entire reproductive system.
No doubt, people believed him, though the notion strikes on as utterly preposterous in 2012. Perhaps he based this on his own erectile problems? Who knows. Regardless, he wrote a book on it, and his shoddy claims were used to argue for denying women higher education and the right to vote. Mr. Clarke would fit in well with today’s Republican Party.
Yesterday, I wrote on the shrinking population of full time, properly compensated faculty in the US academy. I would conjecture that this is to the absolute delight of anti-intellectualists everywhere, who view data and scrutiny as a threat the the future of the Republic.
Socrates was killed for asking questions. One of Pol Pot’s first targets was the educated elite. Here in the US, I can’t foresee policy which calls for the killing of the educated, but I do see our political culture gradually marginalizing us.
As I near the end of my graduate career, I’m filled with anxiety over jobs and money. If an article on Al Jazeera is any indication, those anxieties are entirely founded.
More than 65 percent of all teaching faculty (in terms of credits taught) at American institutions are part time, short term contract workers who are poorly paid and offered little or no benefits at all. Even as tuitions have skyrocketed, full time, fairly compensated job prospects in academia are drying up.
My academic career began when I started teaching math part time at Jackson Community College. Though I was happy to have the opportunity at the time, I worked more than 20 hours a week per course, and was paid the measly sum of $1100 a semester for a 3 credit class. Even if I taught full time for all three semesters (isn’t that a trimester?), I couldn’t reasonably break $14,000 a year, well below the poverty level. Part time instructors had no union representation at the time. We fought for it, but were blocked by both administration (who saw us as an expense) and the current faculty union (who saw us as a threat). I’m not sure what the situation is now.
Eventually, I quit. The poor compensation just wasn’t worth the time put in. Worse, despite poor wages, the school became increasingly intrusive on course design, reporting, management and even whether what we could say in the class room.
There is a direct correlation between freedom on the job and payment. Poorly paid people have little freedom and little respect, well paid people have all the freedom and respect they could ever want. This clearly has vast implications for academic faculty.
The world likes to think that academics live a life of opulence and guaranteed employment. The truth is, that in 2012 most do not. Academics are going the way of just about all employment sectors. Services, even in public institutions, are becoming widely privatized, and the ability of workers to band together and demand improvements in working conditions and compensation undermined. Employer based benefits are disappearing, and compensation is falling. Anti-intellectuals should be rejoicing.
I worry that in 10 years, every university will be taught by robots managing watered down and expensive online courses, geared to giving anybody a fake degree. Academics in the United States is something to be very, very proud of, though the future is very suspect.
Malaria has been around a lot longer than that, but 115 years ago, on August 20, 1897, Dr. Ronald Ross definitely proved his hypothesis that Anopheles mosquitoes transmit malaria to humans.
Ross himself called the day “Mosquito Day,” an anniversary international health professionals (particularly the London School of Tropical Medicine and Hygiene) continue to celebrate. Certainly, if Dr. Ross had not found parasites during his dissection of mosquitoes, someone else would have. Dr. Ross, though, can be credited with speeding up the process of malaria elimination efforts, perhaps saving the lives of billions of children.
Though the discovery of Plasmodium parasites in the gut of Anopheline mosquitoes was vastly important, Dr. Ross most important contribution was his word on mathematical models of infectious disease transmission, which continue to push research to this day.
Though malaria was eventually eliminated from the US, Europe, Japan and a host of other countries following World War II, it continues to kill children throughout most of the developing world. Nearly half the world’s population, 3.3 billion people, lives at some risk for malaria and nearly one million people die from the disease every year.
We still have much work to do, even 115 years later.
An amazing excerpt from his 1923 notebook where he recalls that very important day:
“…The 20 August 1897—the anniversary of which I always call Mosquito Day – was, I think, a cloudy, dull, hot day. I went to hospital at 7am, examined my patients and attended to official correspondence… After a hurried breakfast at the Mess I returned to dissect the cadaver (Mosquito 36) but found nothing new in it… At about 1pm I determined to sacrifice the seventh Anopheles (A. stephensi) of the batch fed on the 16th, Mosquito 38, although my eyesight was already fatigued. Only one more of the batch remained.
The dissection was excellent and I went carefully through the tissues, now so familiar to me, searching every micron with the same passion and care as one would search some vast palace for a little hidden treasure. Nothing. No, these new mosquitoes also were going to be a failure: there was something wrong with the theory. But the stomach tissue still remained to be examined – lying there, empty and flaccid, before me on the glass slide, a great white expanse of cells like a large courtyard of flagstones, each one of which must be scrutinised—half an hour’s labour at least. I was tired and what was the use? But the Angel of Fate fortunately laid his hand on my head; and I had scarcely commenced the search again when I saw a clear and almost perfectly circular outline before me of about 12 microns in diameter. The outline was much too sharp, the cell too small to be an ordinary stomach- cell of a mosquito. I looked a little further. Here was another, and another exactly similar cell.
The afternoon was very hot and overcast; and I remember opening the diaphragm of the sub-stage condenser of the microscope to admit more light and then changing the focus. In each of these cells there was a cluster of small granules, black as jet and exactly like the black pigment granules of the Plasmodium crescents… I laughed, and shouted for the Hospital Assistant – he was away having his siesta… Then I made rough drawings of nine of the cells on page 107 of my notebook, scribbled my notes, sealed my specimens, went home to tea (about 3 p.m.) and slept solidly for an hour…”
Google Maps has come up with an excellent visualization of the global arms trade in small arms and ammunition. Transparency in the global arms trade is low (though reportedly improving). Google and other groups have done an excellent job in pulling back the curtain on the world’s death dealers. Guess who wins?
The United States is, hands down, the largest market for small arms and ammunition. In a marked shift from the early 90’s, the US has increasingly become a major importer of small arms, some of which feeds the domestic market, some of which is procured by the military, and some of which is likely bought at bargain prices and trans-shipped to other destinations through the US. The US now imports large amounts of arms from countries such as Brazil, Russia, Korea and Taiwan.
Gun lobby groups continually send messages about grass roots home protection and fantastical conspiracy theories of doomsday scenarios and jack booted Democrats. It’s quite clear, though, that the small arms trade is major (and growing) part of the world economy. One has to wonder how much grass roots gun rights supporters are being used by a worldwide corporate machine.
Conservative calls for unabated weapon ownership, which clearly has economic drivers, is also an ideological one. Domestic policy friendly to the free trade in guns means international policy that happily encourages the worldwide free trade in weapons. Like domestic ideas that universal ownership will lead to a proactive, strong and paradoxically safer society, worldwide expansion of small arms will eventually lead to safer and freer global trade. The United States, at the behest of the domestic gun lobby, has, in the past, complicated efforts to create international agreements regarding small arms.
The debate is out on whether this is, or is not, true. Domestically, given the myriad factors which determine public safety, teasing out the direct effect of expanded gun ownership on crime is nearly impossible (and no, Switzerland is NOT convincing at all). Internationally, the arguments for expanded militaries is somewhat more convincing. Countries (with the exception of the United States) tend to become more reserved and unwilling to use force once they possess advanced weaponry (ostensibly because of the amount of money it costs to acquire and maintain), though, again, wealthier countries (like Swiss citizens), tend to wish to cooperate economically with their neighbors rather than shoot them.
My feeling is that guns, like bad policies, are easy to make, but difficult to reign in. Having seen people shot (dead) in my lifetime I can’t get behind guns. That someone profits massively off the deaths of those people, makes me ill beyond all description.
The answer to this question is a firm “YES.” Marijuana is widely used throughout Sub-Saharan Africa, and has been for generations. The climate and landscape are more than suitable for marijuana cultivation and the low maintenance nature of the crop makes it ideal for small farmers.
An article in the NYT today covered the growing market for marijuana growers in Swaziland, which feeds demand from surrounding South Africa. Growers of weed in Africa are principally women, used to the back breaking process of tending crops on small patches of land. Growing and selling even small amounts of weed can be a transformative boon to a single mother (or grandmother) struggling to raise several small children.
The illegal nature of marijuana, however, prevents women from demanding fair prices for crops. Small producers receive on a small percentage of the eventual price weed will fetch on the world market. They are forced to sell to a limited number of shady middlemen who are able to demand absurdly low prices for product. Legalizing weed, even in South Africa alone, would allow greater competition among middle men, raising prices paid at market.
The question of marijuana legalization has long been a subject of debate within Malawian politics. Joe Manduwa, a member of the Malawian parliament, called for even partial legalization of weed, pointing out the potential financial benefits. One of Malawi’s largest exports is marijuana, but its illegality prevents the government from taxing and collecting revenue on its sale. Moreover, Malawi is a destination for weed smoking tourists. As long of weed remains illegal, Malawian tour brochures can’t advertise the pleasures of smoking weed on the beautiful Lake Malawi. Weed could become an important source of foreign exchange and domestic revenue, but the Malawian government appears to be either sleeping at the wheel, or deathly frightened of angering the imperial forces of the US/British/Christian axis.
The worldwide export of US and British policy against marijuana is robbing impoverished households of the opportunity to produce saleable and sustainable agricultural products. To me, it’s unforgivable, as the risks of weed pale in comparison to those of legal and state sponsored alcohol and tobacco. The trouble with weed is that anyone can produce it, which violates the industrial centered models of beer and tobacco production, and thus undermines the imagined power of the state as a whole.
Policy makers here in the US must realized that their actions have strong repercussions for the rest of the world. Some old lady in Swaziland, desperately trying to raise her 11 grandchildren, is hoping to get a good price for a bale of weed.
During my recent trip to Vanuatu, I had an interesting conversation with the single worker at the local health clinic on Aneityum, a small island of approximately 700 people. He noted a recent and disturbing rise in sexually transmitted infections (STIs) among the islanders.
The small village of Anelcauhat has a population of approximately 400 people. Out of those 400, approximately 200 (or more) are thought to be sexually active. He reported that he has seen more than 50 symptomatic STI cases in the past 6 months, a shocking number, particularly when one considers that an estimated 70% of all bacterial STI infections are asymptomatic.
The reasons for this are unclear though Aneityum has a long relationship with STIs. In the early 19th century, the population of Aneityum was more than 12,000 (depending on who you ask or believe). By the early 20th century the population had been reduced to a mere 200 people, in part because of a sudden drop in fertility. Gonorrhea and syphilis had rendered the entire female population infertile.
In Vanuatu, like many developing countries, more than 50% of the population is under 24. Youth is a major determinant of risky sex everywhere. A lack of educational resources for youth and low knowledge of STI prevention practices exacerbate the problem and increase risk for everyone. Worse yet, traditional structures make discussion of sexual issues taboo, and male community leaders have been known to discourage condom promotion, thinking that it promotes sex (sound familiar?).
Culture enables increased STI risk. Partnerships in developing countries are often difficult to assess. In some areas of Sub-Saharan Africa, despite the presence of strong religious groups, multiple concurrent relationships are the norm. Concurrent partnerships have long been shown to be a major driver in the HIV epidemic. In Aneityum, formal polygamy does not exist, but any man may have many “Custom Wives” in the community, a connection that must certainly come with extracurricular benefits though people are incredibly vague on the subject.
The shift to cash based economies is fueling STI transmission. Vanuatu, like all developing countries is experiencing not only a population boom, but also an urbanization boom as young people increasingly move to urban areas for jobs, social and economic opportunities. This crates disconnected populations, who often negotiate social connections through romantic partnerships, free of their local watchdogs.
Gender inequality places everyone at risk. Cash wielding older men readily take younger women under their wing, exposing young women to STIs of an older generation. Formal prostitution flourishes where men increasingly have ready cash, and a supply of disconnected, unemployed women rises. No 16 year old girl wants to be a village prostitute where everyone knows her family.
Truthfully, noone knows what the future holds. The fact is, though, that around the world, STIs are diseases of the poor and particularly do well in areas where access to health care is scant. I worry for an area like Aneityum. Clearly, all of the mechanisms to transmit STIs are there. If HIV hits their shores, the entire community would be ripped apart.