So, will West Africa be able to capture the benefits of a demographic dividend?  The answer to this question hinges on how fast West Africa can bring down its high fertility levels.

A new study by Jean-Pierre Guengant for the French Development Agency (AFD) provides a detailed analysis of long-term population and economic trends for 12 Western African countries, i.e., the eight countries of the West African Economic and Monetary Union (WAEMU), plus Ghana, Guinea, Mauritania and Nigeria.

The study acknowledges that economic growth has returned to the region since the mid-1990s.  However, revenues per capita have not increased much.  Assuming a yearly population growth of 2.5 percent and an economic growth of 5 percent per annum, it will take almost 30 years to just double the income per capita, which is already very low to start with.  Worse, total poverty levels ($1.25/day) remain high, between 30 and 50 percent of the population in all countries.  Poverty reduction is all the more challenging for ever growing populations, and so is the formation of human capital.

The AFD analysis offers new population projections, which are made consistent with increases in contraceptive use.  This methodology was proposed by Guengant and myself in a 2011 United Nations Expert Paper.  The intermediary scenario (Medium variant) of the UN population projections assumes sharp fertility declines that are not warranted given the slow increases in contraceptive coverage.  These are currently progressing at the snail pace of 0.5 percentage point per year in West Africa, which is not enough even to achieve the high scenario (High variant) of the UN projections (assuming a slower decline in fertility).

So what are the policy implications?

First, rapid declines in fertility spearheaded by strong family planning programs appear to be one of the prerequisites for sub-Saharan Africa to be able to reap the benefits of a demographic dividend.  The emphasis here is on rapid.

Second, human capital investments and poverty reduction efforts will require huge increases in education and health budgets, to the tune of at least 7 percent per year for the next two decades, a figure well above the current economic growth.

Third, West Africa and Africa at large need to capitalize on the ‘golden moment”, i.e., the boost of family planning efforts that will be discussed at the upcoming family planning summit scheduled in London on July 11.  The time has come for African governments to reenergize their family planning programs.

Too often African leaders and their partners want to believe that the demographic dividend is just around the corner.  This is wishful thinking.  The demographic dividend is not a given, and its chief precondition – the sharp decline in fertility – has not even started in earnest in many West African countries.

For the demographic dividend to present itself, voluntary family planning programs that respect human rights are necessary to trigger much needed fertility declines.  These programs will be useful in their own right as they will serve the needs of millions of African women who want to space and limit their children, but do not have the means to do so.  As these programs will help decrease fertility, they will also facilitate female universal education, which in turn will accelerate the fertility decline.  In short, stronger family planning programs and a faster fertility decline will help usher one of the necessary (but not sufficient) conditions for the countries to reap the benefit of a demographic dividend.

Pregnancy poses a substantial health risk for adolescents. The World Health Organization reports that health problems associated with adolescent pregnancy include increased maternal and neonatal mortality and increased incidence of preterm or low birth weight, among many other adverse health conditions. A study from the British Medical Journal found that complications from pregnancy and childbirth were the leading causes of death for young women between the ages of 15-19 in developing countries.

Yet beyond the health and rights consequences of teenage fertility, little work has systematized the extent of the non-health adverse effects associated with adolescent fertility and the effectiveness of the interventions used to date to reduce teenage fertility in low- and middle-income countries.  In a new paper, Kate McQueston, Rachel Silverman and I aim to fill this gap.

First, we explore trends between adolescent childbearing and socioeconomic outcomes. While the review finds strong correlations between adolescent fertility and school drop-out, the question of causation remains far more ambiguous, as effect sizes decrease sharply with more rigorous research methods. Moreover, the study also finds that in some contexts, high numbers of women continue education after child birth—suggesting that childbirth and education (and other related outcomes) may not be incompatible.

Similarly, the review of interventions to reduce adolescent fertility finds variation across studies, but also notes some general findings. The evidence base for conditional cash transfers, though somewhat variable, is by far the most robust when compared to the other interventions. Additionally, programs that lowered barriers to attending school or increased the opportunity costs of not attending school were also found to be effective—suggesting that education may substitute for adolescent fertility. Notably, the most effective interventions appeared to be outside of the typical reproductive health sphere.

The paper is limited by the quality and scope of the studies available. Further, adolescent fertility and its causes are complex, nuanced issues that are affected by a range of motivations and external factors. Nonetheless, this research reframes the conversation about adolescent fertility and the policies and interventions that might be used to reduce its frequency.

Among other findings, we suggest that adolescent fertility is more consequence than cause of socioeconomic disadvantage. While fertility is often correlated with school dropout, other factors – current school enrollment, marital status, anticipated economic returns to education, family attitudes, and other related context — drive both school continuation and the likelihood of experiencing an adolescent pregnancy. This finding suggests that a more holistic (and possibly complex) approach may be needed to address the foundational causes of adolescent fertility. Creating economic opportunities for women, reducing adolescent marriage, and changing gender norms are likely to be more effective in the quest to accelerate economic development than merely reducing adolescent fertility.

While interventions that focused on increasing knowledge and changing attitudes about sexual and reproductive health appeared successful in the short term, there was little evidence of any long term impact. On the contrary, interventions that encouraged school attendance proved more effective in reducing overall adolescent fertility. This evidence suggests that policymakers should expand educational opportunities for girls and create incentives for school continuation, such as conditional cash payments or the expectation of a worthwhile job following graduation. Reproductive health services are important for many young women, but increasing contraceptive access and uptake may not, on its own, be sufficient to change fertility trends.

As the world prepares for the upcoming family planning summit, it is worth pausing to examine the findings of the growing experimental literature on programs that aim to reduce teen pregnancy and to consider a broader and synergistic approach.

This strong and long overdue pitch to bring back the ‘P’ word into the environmental debate is most welcome.  In recent decades, international attention has shifted from rapid population growth to other urgent issues, such as the HIV/AIDS epidemic, humanitarian crises, climate change, and good governance.  But reproductive health and voluntary family planning programs are still very much needed, especially in high fertility countries, and they require political leadership and long-term financial commitment.  Broader access to family planning services will be needed to accelerate the decline of high fertility rates, particularly in countries where unmet needs for contraception are high.

However, as the report highlights, policies to address population and the environment must go well beyond family planning.  They should stress, first and foremost, the importance of inclusive development.  Today, 1.3 billion people still live with only US$ 1.25 per day.  The international community needs to lift them out of absolute poverty, which will require focused efforts in economic development, education, and health including family planning.  For their part, developed and emerging countries must first stabilize and thereafter reduce their levels of material consumption.  This can be achieved through greater efficiency in the use of resources as well as an array of practical measures to reduce waste, invest in sustainable resources, technologies, and infrastructures, and systematically decouple economic activity from its environmental impact.

Other policy levers should be explored as well.  One should harness the potential for urbanization to reduce material consumption, remove barriers to achieve high-quality education for all at both primary and secondary levels, implement comprehensive wealth measures (i.e., reform the system of national accounts and improve natural assets accounting), and develop new socio-economic systems that are not dependent on continued material consumption growth.  More research is also needed into the interactions between demographic change, consumption, and environmental impact.

I hope the ideas presented in People and the Planet will usher an entirely new way of thinking about population issues and sustainable development and that it will be taken into account at the upcoming Rio+20 Conference.  Population policies and programs should no longer be viewed as necessary and relevant in their own right.  On the contrary, such policies should be integrated with broader and comprehensive interventions that address economic equality, health and education needs, and technological advances.  The ultimate goal should be to improve the life of all human beings as a necessary condition to protect our environment and safeguard the sustainability of our way of living.

Latent demand is thought to be expansive: Despite vast science demonstrating the impact of contraceptive use on fertility, there is still a significant unmet need. Dr. Fred Sai, former Presidential Adviser on Population Issues, Reproductive Health, HIV and AIDS in Ghana showed that modern contraceptive use is still less than 20 percent in Ghana, with usage rate ranges from 50-10 percent throughout the region. Improved access and uptake of contraceptives would help reduce maternal mortality (Africa currently accounts for more than 40 percent of the global burden) and have positive effects on child and economic outcomes (See more on Dr. Sai’s keynote here). While reduced fertility and increased contraceptive use has been correlated with increasing levels of development, there has been debate as to the true source of the “demand” for reproductive health services. CGD non-resident fellow Lant Prichett has suggested that unmet need for contraceptives is virtually non-existent (perhaps with the exception of family planning advocates), as the majority of the differences in fertility are due to individual preferences rather than access to contraceptives.

Studying the effects of existing polices can have surprising results: It was repeatedly stressed during the PopPov conference that analyzing the results of existing policies is often just as important as conducting research to inform the creation of new policies. For instance a presentation by Kelly Jones of IFPRI showed that polices intended to reduce the use of abortion, in this case the Mexico City Policy, actually increased total abortions in Ghana. Similarly, a study by Pörtner et al demonstrated that there was no apparent benefit of family planning programs in Ethiopia for women with formal education—suggesting that improving education may be a viable alternate to family planning. As such, research that evaluates the efficacy of policies can ensure the best use of scare resources.

Context matters: “There are very few Bangladeshi’s in Navrongo.” This was a response from Dr. James Phillips from Columbia University, following a question about why the results of the Matlab project in Bangladesh differed from the impact of the Navrongo project in Ghana. In population policy (and likely all areas of policy), fitting interventions to local context is integral to ensuring the success of programs. Interventions tailored for insular and diffused societies, such as Bangladesh, need to be designed differently from the community based systems that are successful in Ghana. Operational models need to be adjusted for specific cultural and geographic changes. Program designers can’t mechanically assume that one intervention will effectively translate from one side of the world to the other.

Policy communication is integral to research: How can a researcher make sure her findings get into the hands of relevant policy makers?  Most agreed that the key to successful policy communication is to keep the message short and simple using issue briefs to describe larger bodies or work.  And of course, make sure the research answers relevant and timely policy questions!

Making development sustainable: The need for effective population policy is not embraced by all policy makers in Africa. Some governments feel that increased fertility rates will increase market share and strengthen national economies, despite research that shows decreased fertility can lead to higher educational attainment, better health outcomes, and greater labor force participation (i.e. alternatives to increasing market share through income growth). Similarly, it has been argued that decreased fertility is beneficial from the environmental perspective. David Wheeler suggests that population policy is one of the most cost-effective methods to reduce carbon emissions. Of course, like any good research, Wheeler’s work has been debated—since decreasing fertility is often associated with increased income and industrial growth which typically also increases emissions. It’s not clear yet if the issue of sustainable development will become a larger aspect of the population and development debate, but based on the conversations at PopPov, it’s a theme to keep on your radar.

It was clear from the conference that population issues can’t be addressed by the Minster of Health alone. They require cross-disciplinary approaches from education and gender equality, to food security and social insurance. The growing research base on population and development is beneficial in so far as it provides indication for areas of policy changes and innovations, but overall the path ahead is far from clear. What’s great about PopPov is the ubiquitous understanding that the process is a learning experience—and that it takes trial and error sometimes to really figure out ‘what works.’

If you want to read more about this year’s PopPov Conference, I suggest you check out the Population Reference Bureau’s blog for some great posts by Jay Gribble and Eric Zuehlke.

We had a great line-up starting with Professor David Bloom of the Harvard School of Public Health, one of my co-chairs on the CGD working group that looked at UNFPA on the occasion of its recent leadership transition. David presented our motivation for the report and the working group recommendations.  My other co-chair, Dr. Jotham Musinguzi, who heads the Africa regional office of Partners in Population and Development, then talked about the way UNFPA operates in countries. After all, the vast majority of its resources are in country offices, so that’s the true test of its effectiveness. Panelists Jill Sheffield, president of Women Deliver, and Jonna Jeurlink from the DFID mission to the UN talked about their perceptions of UNFPA as a partner and as a recipient of funds, respectively.

I gave a few opening thoughts about what makes the development context interesting and challenging these days, and how that is relevant to UNFPA. The current financial climate has prompted a useful examination of how aid is working and what governance arrangements and technical modalities are best suited for the future. There are many new initiatives aimed at mobilizing resources, transforming advocacy, and aligning national strategies with international commitments. Most are also trying to increase harmonization, accountability, and transparency among donors and institutions.

Conditions are in flux and the issues we raised in the report of governance, results, effectiveness and communication are timely, offering a unique opportunity to examine how UNFPA can best position itself and its objectives to be effective. Its small size and voluntary resource base can be an advantage if it can be nimble, laser-focused, while consolidating gains and emphasizing common ground. But this new context raises many questions as well.

The working group’s four recommendations for action pose and strive to answer various questions to help UNFPA make tough choices. Can UNFPA to stick to the International Conference on Population and Development (ICPD) Programme of Action and also work on sexuality? How can they put youth in the forefront and also deal with rapidly aging populations? And how should UNFPA link to the Global Strategy for Women and Children and to UN Women, while not being redundant?

Granted, UNFPA lives in a particularly more polarizing and politicized space than almost any other UN or multilateral agency, as we’ve observed recently in Washington. Although recent congressional attempts to completely defund UNFPA failed, its funding for the current year was cut by $15 million. Yet, those financial and political challenges will not disappear. The reproductive health and family planning community should embrace and study the assessments now available on the global stage, including the CGD report and the DFID findings, and use them to show friends and foes alike UNFPA’s essential role in a new era.

Over the course of working on this project for the past year, we heard from many people in many places. We heard strong and articulate views about what UNFPA is and should be, some of them very extreme (I’ll leave those to your imagination). I was particularly surprised by the disparity in views, both about what UNFPA is, and what it should be. This implies that UNFPA’s vision may have become somewhat blurred, and needs to be focused. That is the Working Group’s first recommendation.

We met a few weeks ago with UNFPA’s new executive director, Dr. Babatunde Osotimehin, and his senior staff to share the recommendations and discuss the way forward. Dr. Osotimehin is currently gathering input from inside and outside of UNFPA and will present his plans for the Fund to UNFPA’s Executive Board this fall.  We received some assurances that the working group’s recommendations would be part of their on-going strategic planning.

The next few months are a crucial time for all who wish to see UNFPA move into its fourth decade as a stronger and more effective organization. We encouraged those who gathered in New York to keep up the pressure on UNFPA to not boycott the discussion. The member states – especially Executive Board members and those diplomats and country delegations closely involved in population, reproductive health, and family planning issues – along with key civil society organizations, should study what is in the report, consider what it says and who said it, and then decide how to act to help UNFPA achieve the shared goals of greater effectiveness and alacrity in improving women’s health and well-being.

Courtesy U.S. State Department

When it comes to Secretary of State Hillary Clinton, no sliver of the international development community is more enamored than the sexual and reproductive health and rights (SRHR) crowd (yes, that’s their self-designation). Last Friday, Hillary returned the love. In a speech (see the full text here) in the regal Benjamin Franklin reception room at the State Department, Secretary of State Clinton and many of her top staff brought the international dimension of reproductive health and family planning in from the cold. It’s been a long winter.

The occasion of the speech was the 15th anniversary of the “Cairo Conference” – officially the International Conference on Population and Development (ICPD) – in 1994, at which then-first lady Clinton was a very prominent and passionate leader of the U.S. delegation. Last Friday she said,

There is no doubt in my mind that the work that was done and the commitments that were made in Cairo are still really the bulwark of what we intend to be doing and are expected to do on behalf of women and girls.

The ICPD was particularly ill-timed. Several months later, Republicans took control in the U.S. Congress and anything having to do with sex, rights, or Hillary became a political cudgel. The conditions for advancing the Cairo Plan of Action on SRHR became worse in 2000 when George W. Bush took office, the Mexico City policy (known by some as the global gag rule) first imposed by Ronald Reagan was reinstated, U.S. funding was pulled from the UN Population Fund (UNFPA)and replaced by Nordic and other European countries and the U.S. became a pariah in international circles concerned about women and their rights.

The SRHR crowd in the U.S. went into exile. They’ve been there for almost half the time that has elapsed since Cairo. As Margaret Pollack (newly appointed Senior Advisor on Population Issues at the U.S. State Department) said at a UN Foundation luncheon to celebrate Friday’s speech, a lot of time has been lost that could have been spent achieving the Cairo Plan of Action – and not incidentally, getting much closer to achieving MDG 5, the maternal health goal.

Secretary Clinton seems to be in a hurry to make up for lost time. She used the full arsenal of her top staff and emboldened them with strong words. Eric Schwartz, assistant secretary of state responsible for population issues, opened the event saying, “We recommit to the principles of ICPD and its Plan of Action.” Ambassador-at-Large for Global Women’s Issues, Melanne Verveer, in introducing the Secretary, called her a woman who has not wavered on the issues of SRHR and applauded the focus on girls and women in the Secretary’s “groundbreaking speech on development” two days earlier at CGD. (For those who missed it, you can read the text of the prepared remarks here – note the very nice reference to Start with a Girl in her sixth point.)

Maria Otero, the undersecretary of state for democracy and global affairs, drove home the point that the Secretary is dead serious about putting the needs and condition of girls and women at the center of U.S. foreign policy. And completing the all-star line-up, USAID Administrator Raj Shah, sworn in just the day before, assured the crowd that a newly energized and excited USAID is ready to live up to the core principles of SRHR and the full vision that the Secretary articulated in last Wednesday’s speech – a speech he called “the most important statement on development by a secretary of state in decades.”

So what did Secretary Clinton deliver in her tidings of comfort and joy? (this speech was originally scheduled to happen right before Christmas but a Washington DC blizzard delayed it.) Four points that pretty much capture the essence of what’s needed:

1. Girls and Women: The Secretary not only “Started with a Girl,” but she put girls in the center and at the end of her speech as well. After reciting some of the brutal statistics that describe the sorry state of women’s and girls’ health – including a woman dying every minute of every day from pregnancy and childbirth and 70 million women and girls worldwide with their genitals carved up – she declared the situation intolerable. (For a discussion of the available statistics on girls, see Ruth Levine’s blog here.) In addition to reinforcing on-going U.S. programs to prevent maternal mortality and female genital cutting, the Secretary is asking every program in the State Department and USAID to determine what its contribution is for the well-being of girls and women. That will require some careful searching, but it is the soul-searching that will accompany it that could most change the State Department.
2. U.S. as a global leader: I felt an undercurrent of last year’s inaugural mood in the Benjamin Franklin room as the Secretary and her cadre spoke of the future. They were wiping away 8 years of U.S. blockage and manipulation of international family planning programs and policy negotiations. There was a sense of pride and almost disbelief in the audience that the reversal could be so complete. The members of the diplomatic corps that I spoke with afterwards were perhaps the most gratified. One ambassador said to me, “Now, when the U.S. speaks, people will listen again.”
3. More money: Getting down to the important details, Secretary Clinton said, “We’ve pledged new funding, new programs, and new commitments to MDG5.” The Obama Administration has already renewed funding to UNFPA and “more is on the way,” according to the Secretary. She said there will be in increase in population funding within the U.S. budget (as we’ve seen already, by almost one-third), and reproductive health and family planning , in addition to maternal and child health, will be central to the Global Health Initiative being constructed by a constellation of USG agencies in time for the President’s budget speech in February.
4. Centrality of SRHR to development: Perhaps most challenging but key to it all is the connection between SRHR and so many other development goals. Secretary Clinton gets it in spades, and so she said, “We understand there is a direct line between a woman’s reproductive health and her ability to lead a productive, fulfilling life. And therefore, we believe investing in the potential of women and girls is the best investment we can make.” And some concrete actions: “We are integrating women, adolescents and girls into our Global Health Initiative and our Food Security Initiative. We will make sure the integration of family planning happens…all health programs will be designed to take into account women and girls.”

I daresay that not just the SRHR crowd – stalwarts all—were pleased when she said off-script,

“I know it can sometimes be hard to take, we might grow weary of the ups and downs in these things that seem so self-evident to the rest of us that this must be done. But work with us, and let’s create structural and institutional change that does not get wiped away with the political winds.”

For those of us in the development community who are immersed in questions of how to achieve better health in the developing world and/or issues of the empowerment of women, the renewed attention to the health of girls and women is very welcome. At the same time, it’s hard to quiet the inner questions about how to reconcile enthusiasm for SRHR within the “international community” with the much less positive view in many of the governments of developing countries. While it is certainly the case that in some countries receiving U.S. development assistance (for example, Ethiopia and Egypt) there appears to be genuine high-level support for family planning and good reproductive health care, this is far from a universal position. At best, countries that are not actively supportive will permit family planning services to be provided when donors pay – which is why there is a dramatic ebb and flow of access to services depending on the party affiliation of the President of the United States. At worst, the policies and practices of governments with which we do development business are retrograde with respect to the health-related rights of girls and women.

This puts us in a little bit of a bind when it comes to simultaneously insisting on the value of a women-centered approach in health and the principle of “country ownership” and engagement in true partnerships – a priority for development policy that Secretary Clinton articulated in her address earlier in the week. One way to manage that conundrum is to invoke the fact that the vast majority of the world’s nations are signatories to the Convention on the Elimination of All Forms of Discrimination Against Women and the Convention on the Rights of the Child, which include provisions that cover almost all of actions that SRHR advocates promote. Therefore, as signatories they have already endorsed access to quality health services, protection from gender-based violence, and many other important objectives. But, sadly, the bind becomes tighter if we attempt to use this rationale because the U.S. is among the very few countries that has ratified neither of those conventions – along with Iran and Sudan in the case of CEDAW, and Somalia in the case of the CRC. In this domain, we fall far short of being able to serve as a model or inspiration – and are significantly challenged even to highlight the disconnect between other countries’ rhetoric and practices.

In spite of these significant reasons for caution, we can all bask for a moment in the reflected warmth from the end of the SRHR community’s long winter in exile.

When the Lancet published “Global patterns of mortality in young people: a systematic analysis of population health data” by George Patton et al., it brought into the public domain new data to tell an important story: adolescent boys and girls are at risk during this transitional life phase, and those risks have major implications for the health and well-being of this and the next generation.

The article highlights just how much boys’ and girls’ lives diverge with adolescence and how gender fundamentally affects health. Traffic accidents cause 14 percent of deaths among males 10-24 years old deaths but only 5 percent of female deaths; violence causes 12 percent of male deaths but doesn’t even feature in the “top ten” for females. For girls and young women, the major causes of death are maternal factors, at 15 percent.

The study improves upon earlier research that did not break down data by age and sex, but we’re still a long way from having a full picture of the health of teens. Because the focus is on causes of death – a relatively rare event in adolescent populations – it offers only incomplete and indirect evidence about the full burden of disease, which includes sickness and disability as well as fatalities. For adolescents, perhaps even more than for the infants and children, what matters most is found in the day-to-day assaults on wellbeing, rather than deaths.

We’re talking about the non-fatal diseases that affect adolescents, often with serious current and long term consequences. For girls, anemia, human papilloma virus, and other untreated sexually transmitted infections precede a cascade of health problems at older ages and among their future children. Girls and women pass health problems on to their children, an unfortunate legacy exacerbated when girls become mothers before age 18 – a common situation in many developing countries. Unhealthy girls make for continuing cycles of ill health and gender inequality.

We’re also talking about the life-long health behaviors established in the teenage years (and even earlier). Patterns of eating, physical activity, sexual behavior, tobacco and drug use among today’s adolescents underlie a large part of WHO’s prediction that non-communicable health problems will cause more than three-quarters of all deaths in 2030.

It’s an adolescent world out there and without more focused attention on young people, spirals of ill health, poverty, and gender discrimination will persist. As noted in the Lancet, many of the health problems of adolescent girls, and indeed boys, are preventable; proven solutions are available. The opportunity to do something grand with a new agenda for global health is at our fingertips: start with a girl and the rest will follow.

The author, Yazeed Kamaldien, seems to find solace in the fact that “these drugs are used only to treat primary TB, however, and not other cases, such as multi-resistant TB.” He appears to completely misunderstand a primary cause of MDR-TB (multi-drug resistant TB) and drug resistance in general. While he is correct to breathe a sigh of relief that this discovery will, hopefully, not cause any MDR-TB cases to become the virtually untreatable XDR-TB (extremely-drug resistant TB), episodes such as this undoubtedly increase the risk of resistance among uncomplicated, primary TB patients. As MDR-TB can cost up to 300 times as much (in time, money and human resources) to treat as primary TB, these errors can put incredible strain on an already weak health system.

Also disturbing is the fact that this episode comes right on the heels of a recall of anti-retrovirals (ARVs), manufactured by Adcock Ingram to treat patients with HIV, after a packaging mix-up last week. At a time when news reports of substandard, counterfeit therapeutics in the developing world are dominated by stories on antimalarials, I hope that these South Africa cases do not signal a new trend.

A recent study conducted in six African countries found that only around 1/3 of the antimalarials purchased in local pharmacies were of a high quality and not in violation of WHO guidelines. My colleague, Rachel Nugent, discusses these findings in a recent blog and asks some probing questions about the cause of the substandard products. Whatever the reason (and there can be many), it is vital to find out, because if poor quality drugs are still making their way to the sick, it will terribly undermine treatment efforts – not only by not curing the patient, but also by proliferating the epidemic of drug resistance.