Check out a new book chapter authored by Aashish, Diane, and Dean, called “Purity, pollution, and untouchability: challenges affecting the adoption, use, and sustainability of sanitation programmes in rural India” in the book “Sustainable Sanitation for all: Experiences, challenges and innovations“, published by Practical Action and edited by Petra Bongartz, Naomi Vernon and John Fox.
Angus Deaton’s Nobel lecture is Tuesday. You can watch it online here, at the Nobel prize website.
The lecture is at 1:30 pm Central European Time. To make life easier on everyone in r.i.c.e., that’s:
- 6:00 pm here in India,
- 7:30 am for board members John and Louis in the U.S. east, and everyone in Princeton,
- 6:30 am for Mike in Texas,
- 4:30 am for Josephine in California, and, of course,
- 1:30 pm for Nicholas in France.
Today, Diane’s article on maternal undernutrition and maternity entitlements came out in India in Transition, as well as the Hindu Businessline. Here is the text of the article from Hindu Businessline:
Healthy mothers give birth to healthy children who grow up to be productive adults. By contrast, women who begin pregnancy too thin and do not gain enough weight during pregnancy are far more likely to have low birth-weight babies.
In India, low birth-weight is the leading cause of neonatal mortality, or death in the first month of life. Neonatal mortality accounts for about 70 per cent of infant deaths in India — and is far higher than would be predicted by India’s GDP. India’s high neonatal mortality rates is a symptom of widespread maternal malnutrition.
How does India fare on important indicators of maternal nutrition, such as pre-pregnancy body mass and weight gain during pregnancy? My recent research finds that 42.2 per cent of Indian women are underweight at the beginning of pregnancy. This means they have a body mass index (BMI) score of less than 18.5, which is the Food and Agriculture Organization’s cut-off for chronic energy deficiency. This is an extremely high rate of underweight among pregnant women, even relative to poorer, less developed regions of the world; only about 16 per cent of women in sub-Saharan Africa are underweight at the beginning of pregnancy.
Not only are Indian women too thin when they begin pregnancy, they do not gain enough weight during pregnancy to compensate for low pre-pregnancy body mass. Women in India gain only about 7 kg, on average, during pregnancy. This is far too low to produce a healthy baby; it’s only about half of what the US Institute of Medicine recommends for women in the US. Unfortunately, this topic has been studied very little by Indian researchers and the government; no national guidelines for weight gain during pregnancy are available.
Poor maternal nutrition has serious consequences for the health and human capital of the Indian population. It leads to low birth-weight, and is likely an important reason why Indians are among the shortest people in the world. The fact that Indian children and adults are so short is a sign that they are not achieving their cognitive potential. Researchers now understand that the same early-life health processes that stunt child height also affect the development of their brains. Children who are stunted are less likely to be able to read, and grow up to earn lower wages than taller people. Thus, maternal nutrition, low birth-weight, and stunting are not only health issues, they are also economic issues.
Patriarchy and malnourishment
Why are pregnant women in India so poorly nourished? One important reason is because, as young women living in a patriarchal society, they have very low status in their households. While over 40 per cent of young women who get pregnant are underweight, a smaller fraction of middle-aged men — about 25 per cent — are underweight. If food and work were shared equally between family members within households, we would expect to see similar fractions underweight for these different demographic groups. Instead, many prior studies confirm that young, newly-married women are often treated poorly by their own family members and are expected to be self-sacrificing, do hard work, and eat little.
Although there is important regional variation in women’s health, and in a number of measures of gender inequality in India, with the south outperforming the north, improvements in women’s status would likely result in better child outcomes everywhere. My recent research, with Reetika Khera and Dean Spears, on joint households in rural India, provides further confirmation of the importance of intra-household status for nutrition.
It finds that daughters-in-law married to the younger brother in a joint household are thinner than daughters-in-law married to the older brother due to the fact that women married to the older brother have higher intra-household status than women married to the younger brother. This research shows an effect of social status on maternal health in a way that is unlikely to be confounded by other factors. It also finds that poor nutrition in pregnancy is one way in which the low social status of women can affect the health of the next generation.
The fact that poor maternal nutrition is related to social hierarchy and the low social status of young women in Indian households makes it a very difficult issue for the government to address. Changing how husbands treat their wives, how mothers-in-law treat their daughters-in-law, and whether women stand up for their own and their infants’ health will not happen overnight. However, the costs of taking a business-as-usual approach to poor nutrition in pregnancy are simply too high to ignore.
Measuring maternal health
An important first step in addressing poor maternal health is to measure it. India has not had a National Family Health Survey (NFHS) for 10 years. Thankfully, a new NFHS is being carried out right now, but in order for these surveys to be more useful, they must be implemented regularly. Bangladesh, for instance, carries out a similar health survey every three years. In addition to conducting a regular NHFS, India should implement a continuous national monitoring system to track a representative sample of women throughout pregnancy and delivery. Such systems are in place in other countries, and cost very little. With a continuous monitoring system in place, the government could more easily experiment with new maternal health programmes, such as maternity entitlements, and see how birth outcomes respond.
Under the National Food Security Act, pregnant women are entitled to receive ₹6,000 in maternity benefits. Unfortunately, it has been more than two years since the NFSA was passed, and maternity entitlements have not yet been implemented. This is a missed opportunity to begin addressing India’s abysmal maternal nutrition. Although it is not likely that maternity entitlements could reduce the prevalence of pre-pregnancy underweight, a well-designed maternity entitlements programme might help improve weight gain during pregnancy.
The government should experiment with pairing education about the importance of weight gain during pregnancy, and put pressure on families to take better care of pregnant women, with a lump-sum, unconditional cash transfer to women as early in pregnancy as beneficiaries can be identified (when it could still potentially be spent on more nutritious food for the pregnant woman).
Such a design would make the programme relatively easy to implement, and might signal the importance of greater weight gain during pregnancy to beneficiaries and their families.
If you would like to attend the conference, you must register by here by 25th Sept.
Last year, the Government of India launched the Swachch Bharat Mission, aimed at eliminating open defecation by 2019. How can the widespread adoption of latrine use be accomplished?
To this end, the Indian Institute for Dalit Studies and the research institute for compassionate economics are organizing a half-day Conference on Purity, Untouchability, and Open Defecation: Starting a Conversation for a Swachch Bharat, hosted at Jawaharlal Nehru University. The goal of the conference is to explore the connections between these issues and deepen a dialogue between organizations working in these fields.
The conference will have the following presentations of original research:
- Dirty, disastrous and desolate: engaging with conservancy workers to understand caste and work inter-sectionalities, Dr. Sanghmitra Acharya, Director of IIDS and Professor at JNU;
- The continuing practice of untouchability in India: patterns and mitigating influences and implications for open defecation, Dr. Amit Thorat, Associate Fellow at NCAER;
- Purity, pollution, and open defecation: evidence from new qualitative and quantitative data, Ms. Sangita Vyas, Managing Director for Sanitation at r.i.c.e.
A policy panel will conclude the conference, on which Dr. SK Thorat (Chairman of the Indian Council of Social Science), Mr. Bezwada Wilson (founder of the Safai Karamchari Andolan), Mr. Sujoy Mojumdar (Water, Sanitation, and Hygiene Specialist at UNICEF), and Mr. Avinash Kumar (Director Policy and Program at Wateraid), among others, will be participating.
We look forward to your participation in this event. Others from your organization are also welcome to attend. All participants must register here by 25th Sept.
Date: 29th Sept, 2015
Time: 9:00 am to 2:00pm
Place: Convention Centre, JNU
Yep. Its at the India Habitat Center, on Sunday. Here is the link for the event. When the video is available on the internet, we will link it here.
Please go to livemint and see Nikhil and Aashish’s op-ed on the struggles being faced by the new Swachh Bharat Mission. They compile a lot of data from the website of the Swachh Bharat Mission to present the case that the mission is not any different from the Swachh Bharat Mission, and in some ways, may even be worse. It reduced spending on behavior change spending, for certain.
The government’s plans to monitor toilet building as a part of the Swacch Bharat Mission were highlighted this week in USA Today. The article quotes from the SQUAT report to make the point that simply building toilets will not be enough, and that without building awareness and changing preferences for sanitation, efforts to end open defecation are unlikely to work. While it is true that official policy envisions public education as a part of the government’s efforts, we have yet to see a true campaign to change people’s minds on the ground. Check out the article here!
Scroll.in did a report on Aashish’s paper “Reporting and incidence of violence against women in India“. Check out the article here. It says,
When thinking of sexual violence, most people imagine the perpetrator a stranger lurking in the dark. In reality, as a new study reasserts, most cases of sexual assault in India are perpetrated by people the women know. In fact, the number of women sexually assaulted by their husbands is 40 times the number of women who suffer such violence from others. The study, by Aashish Gupta of the US-headquartered RICE Institute, cites statistics published by UN Women in 2011, which say that one in every 10 women has suffered sexual assault by their husband and one in three has faced physical violence from the husband or intimate partner.
Hindu’s Rukimini S, our favorite data journalist, also did a follow-up story. She said,
The last NFHS showed that the vast majority of sexual violence reported by women was within the marriage; just 2.3 per cent of rape that women reported to the NFHS interviewers was by men other than the husband, researcher Aashish Gupta found.
The BBC, meanwhile, replugged Rukmini’s previous story. It said,
A new study has found that sexual violence against women is “grossly under-reported” in India, says The Hindu.
The research, by social scientist Aashish Gupta, has established that just 1% of marital rapes and 6% of rapes by men other than husbands are reported to the police.
The paper notes that in general, states associated with gender equality – the north-eastern States, Kerala, Tamil Nadu and Karnataka – had both lower levels of actual incidence of violence and higher levels of reporting.
These days, we end up writing so many articles that we miss some of them on this blog. We are sorry. One such article was by Payal, written for the cool website scroll.in. The full text of the article is appended below (they also used our photo).
Imagine that you are from rural Uttar Pradesh. You live in a kaccha house with your family, with your brother’s family living next door. You have defecated in the open your whole life. It’s something that you consider to be good, even healthy: going out in the open early in the morning gives you the chance to take a walk, get some fresh air, check on your fields, and meet your neighbors.
Then one day, your brother decides to build a latrine for his family. He invests a fair amount of money into it, making sure that it has a large pit and pucca walls. Only some members of his family use the latrine, like his pregnant daughter-in-law, since everyone else prefers to go outside. Although a latrine has been constructed just next door, that too in your brother’s home, you would never consider using it regularly. It might be alright to use it “in emergencies” but otherwise, you and your family continue to defecate in the open every day.
With the launch of the Swachh Bharat Mission today, there are many who are vigorously advocating community latrines as a real policy solution to ending open defecation in India. The idea is that if we can build a few toilets for use in rural communities, where close to 90% of India’s open defecation occurs, then people without latrines in their homes can use them to avoid going out in the open. But the story above is a common one. In addition to widespread lack of demand for latrine use and social fragmentation that makes the maintenance of shared latrines difficult, there is a clear discomfort in rural India around the idea of sharing latrines, making community latrines unlikely to work.
My colleagues and I at the Research Institute for Compassionate Economicsrecently conducted a survey of sanitation attitudes and practices in over 3,200 households in rural Uttar Pradesh, Madhya Pradesh, Rajasthan, Bihar, and Haryana (the SQUAT Survey). What we found is that people in rural north India very often do not use, and definitely do not share, their latrines.
There are a few important reasons why community latrines in rural India are unlikely to reduce open defecation. First, many people who have latrines in their own homes continue to defecate in the open, so it is misguided to assume that they would use a community latrine if it were available. In our survey, over 40% of households with a working latrine had at least one member who still defecates in the open. In fact, almost half of people who defecate in the open say that they do so because it is pleasurable, comfortable, or convenient. They are not interested in someone building them a toilet, and so a community toilet will not suddenly make them want to use one.
Second, people in rural India do not share latrines. According to 2012 UNICEF/WHO data, while 20% of urban households without a household latrine used a shared or public toilet, only 5% of rural households did. Our survey similarly showed how infrequent latrine sharing is in rural India: less than 1% of households without a latrine use a community latrine. The discomfort with latrine sharing is demonstrated clearly by the fact that only 7% of households in our study that have a working latrine reported that non-household members also use it. We spoke to many households, like the one above, in which even brothers living next door to one another don’t share their latrines. Though it is possible that attitudes can change, sharing latrines is incredibly uncommon, suggesting how difficult it will be to make community latrines a palatable alternative to open defecation, if we can manage to convince people to want to use a latrine at all.
And third, it is naïve to simplify villages into homogenous communities that live in harmony and care for the wellbeing of all their neighbors. Rather, people are divided along lines of gender, religion, caste, and economic status that make cooperation complicated. Community or public toilets in urban India are difficult to keep in good condition, but still might be a good solution for the urban context. However, it is improbable to assume that people in rural India will use community toilets, coming together to maintain them so that they are available for those who need them. With such deep divisions, in an environment where latrine sharing is already so rare, why would entire villages share them?
What India needs is a Latrine Use Revolution. Community toilets are just another construction-focused solution to the problem of open defecation. As long as people continue to resist building and using latrines in their own homes, or in the homes of their family members, they will not use community latrines. Let’s shift the focus of the upcoming Swacch Bharat Mission to changing behavior, and convince every rural Indian that they want to use a latrine rather than go in the open. Only then will we truly make progress on making India free of open defecation by 2019
Check out Aashish and Payal’s article in today’s Indian Express, calling for a Sanitation Sena in India, and they made a very cool cartoon too!
Sangita, Jeff Hammer, and Jayamala Subramaniam, rang in the Swacch Bharat Mission on India at 9 with Anubha Bhonsle last night. The show culminated with Bhonsle summarizing, “The emphasis has to be on behavioural change.” Their segment of the show starts at 33:00.
For ensuring hygiene, waste management and sanitation across the nation a “Swachh Bharat Mission” will be launched. This will be our tribute to Mahatma Gandhi on his 150th birth anniversary to be celebrated in the year 2019.
– Address to the Parliament – June 2014 – President Pranab Mukherjee
The need for sanitation is of utmost importance. Although the Central Government is providing resources within its means, the task of total sanitation cannot be achieved without the support of all. The Government intends to cover every household by total sanitation by the year 2019, the 150th year of the Birth anniversary of Mahatma Gandhi through Swatchh Bharat Abhiyan.
— Budget Speech – July 2014 – Honourable Minister Arun Jaitley
The Government of India has announced a new Swatchh Bharat Mission, or Mission for a Sanitary India. The details of the Mission are currently under development. We recommend the following five principles:
1. Reducing open defecation is the top priority. Although there are many benefits of a cleaner India, it is open defecation which kills hundreds of thousands of children each year and limits the development of those who survive. Open defecation shall be the top priority of the Mission.
2. Central measurement of latrine use. Recognizing that any goal that is not measured is not achieved, the Swach Bharat Mission shall establish an independent, accountable mechanism of monitoring latrine use, not latrine construction.
3. Achieving latrine use requires promoting behaviour change. Information, education, and latrine use promotion shall be the cornerstones of any successful Mission to end open defecation. Officers shall not be asked how many latrines they constructed; instead, officers shall be held to account for what they did to change minds and behaviour and to promote latrine use.
4. Latrine use requires a ground staff. Rural sanitation teams at the block and district level require a new, dedicated staff responsible only for behaviour change and promotion of latrine use, not for latrine construction. Officers shall be rewarded for trying and learning from new ideas, whether they succeed or fail.
5. Learn from doing and learn from the best. The Government shall lead a programme of learning from successes, failures, and challenges of attempts to change behaviour and to promote latrine use. The Mission shall learn from the experiences of the Pulse Polio campaign, from leaders in the field of marketing, and from experts on rural sanitation behaviour.
WordPress tells us that this is our 200th post on the r.i.c.e blog. We thank you, our readers, for being with us all this while.
We wrote two new articles this past week. Actually, we wrote more, but only two of them have come out.
The first one, written by Dean for the website niticentral.com, argues that the goal of eliminating open defecation, as articulated by India’s new prime minister, Narendra Modi, makes economic sense. To know why, read the article here.
The next one, written together by Diane, Aashish, Payal, Dean and Sangita discusses the different problems of open defecation and violence against women. In particular, its a nuanced response to the media commentary on recent incidents of sexual and caste violence against women. Read here.
More articles, which discuss the findings of our recently concluded SQUAT survey, are on their way. Stay tuned.
Jairam Ramesh, who in his short tenure as India’s minister for Sanitation (and in his longer tenure as Rural Development Minister) did a lot to advance the cause of ending open defecation in India, has a new article about ending open defecation in India today.
Today a number of issues should unite political parties, not divide them. Extremely poor environmental and household sanitation is undoubtedly the most glaringly obvious of these; yet we seem to have reconciled and adjusted ourselves to this grim situation.
We could not agree more. He also says,
Modi as Prime Minister must give a different call: For a “Khule Mein Shauch-Mukt Bharat” (Open Defecation Free India). If he does so, I’m confident all parties will extend their hand of cooperation.
Thank you, Jairam Ramesh, for saying that. We certainly hope that this happens.
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research institute for compassionate economics
Open defecation kills Indian children and stunts their growth. Since open defecation is so bad for people, why do almost more than half of Indian households lack access to toilets? We need your help to find out! Read on to find out more!
India has exceptionally poor sanitation: the country accounts for 60% of the incidence of open defecation in the world, and open defecation is important issue of human dignity and a cause of avoidable disease, mortality, and malnutrition (for more on this, see here).
However, we do not understand very well the reasons why such a large proportion of the Indian population does not have access to toilets. The research institute for compassionate economics (rice) is looking for capable and hard-working investigators to help conduct the Sanitation Quality Use Access and Trends (SQUAT) survey in parts of rural India. This research will help understand why access to sanitation is low in India, while also identifying the various behavioral and policy bottlenecks in the path of toilet ownership and use in rural India.
Investigators for this important survey will be trained, work in teams, and visit about 30 districts in eight states. This is full time work, starting mid-November, for five months. rice will cover food, accommodation, travel and all related expenses. Investigators will be given vacation/rest time every few weeks. We promise a fun and enriching experience, lots of learning, and decent salaries. If you are interested, please fill this form – applications are rolling, so we encourage you to fill it up NOW. We need both men and women; and candidates from all social backgrounds are encouraged to apply, but competency in Hindi is a must.
On behalf of rice,
For the last several days, most of the rice team has been in Bangladesh trying to understand how they did it. Did what, you ask? Reduce open defecation, of course!
It turns out that open defecation is pretty rare in Bangladesh, about 10% of households in the 2011 DHS defecate in the open. (I counted “hanging toilets” if you were wondering why this statistic is somewhat higher than some of the other published statistics on open defecation in Bangladesh.) We have been learning from some extremely dedicated and talented people about an amazing story of cholera emergencies, household demand for toilets, the power of market forces in supplying affordable latrine parts, and the sustained and well-orchestrated efforts on the part of many, many NGO workers, as well as government, to spread latrines throughout the country. Stay tuned with us as we post pictures from our travels to rural Bangladesh. We’ll also write more about this amazing story, from India’s neighbor: a story about babies surviving to grow tall and healthy, thanks to the efforts of many to make Bangladesh a country where people use latrines.
Here’s a couple of pictures from our one day field visit with BRAC to a village near to Dhaka.
Check out this link to a discussion of rice’s work on sanitation, stunting, and the height conference in TIME magazine. You can also click on TIME’s picture reprinted here for a link to the story.
We have already talked in depth on this blog about how open defecation is worse for health in more populated areas. Because the fecal germs of one person can make anyone sick, the health effects related to open defecation are worse in areas where the likelihood of being exposed to other people’s fecal germs is higher. As the number of open defecators increases in a given area, the health effects will be more pronounced. In fact, children growing up in areas with a greater incidence of open defecation per square kilometer are on average shorter.
Our friend Jeff Hammer and some of his colleagues have spent the summer delving into this issue further by exploring how health outcomes may be geographically distributed over very population-dense areas, the slums of Delhi. I recently saw Jeff present some of the preliminary results from this research here in Delhi at NCAER.
They mapped out open defecation areas, open sewers, sewage outflow areas, and garbage dumps, all places where one could come into contact with fecal pathogens, and interviewed households around these areas. Their initial hypothesis was that individuals who lived closer to unsanitary places were more likely to have diarrhea, but what they ended up realizing was that there are lots of minute, hard-to-measure characteristics that mediate exposure to fecal pathogens from the surrounding environment. For instance, whether the gradient of the pathway outside is tilted toward or away from the house, or whether a hut is slightly lower lying or slightly raised are the kinds of factors that determine whether and how often fecal pathogens enter the home. But there are too many of these little micro-level details that are important. It would be almost impossible, or at least very expensive, to collect data on all of them. So the researchers cleverly decided to use a variable that gets at what really matters: whether water from the street has come into the house in the last year.
What they find is that individuals who reported having diarrhea in the past two weeks are significantly more likely to live in houses that have had water from the street enter the home in the past year. Incidence of diarrhea in the past two weeks also increases with the number of open defecators within 2.5 kilometers (using GIS data) and with someone in the household sometimes defecating in the open. These results are robust to the inclusion of controls like education, gender, water source, caste, neighborhood, and age. And the results do not hold for other types of health conditions like fever and cough, which suggests that its not that these people are just unhealthy.
One thing that I like about this study is that it reminds us again of the importance of sanitation spillovers. Using household-level data and a more proximate measure of health (incidence of diarrhea), this study arrives at the same conclusions as studies that use more aggregated data from the Demographic and Health Surveys and a more long-term measure of child health, height (see here and here). All of these studies come to the same conclusions: there are externalities associated with sanitation.
Importantly, it also highlights the point that where stuff flows afterwards is as important as where stuff goes in the first place. Not only is it important to get people to use latrines and toilets, it is just as important to make sure that what goes into the toilet does not just find its way right back into peoples homes afterwards.
You can see Jeff’s slides from his presentation at NCAER here.
Our team is always telling me that I have to put more pictures in my blog posts. Unfortunately, in my quick trip to Bangalore last week to meet with Arghyam I didn’t actually get to go see any rural latrines, so what we are stuck with is a picture of me presenting:
But the real purpose of this post is to thank my new friends in Arghyam for an interesting day where I learned about their new ideas for a Behavior Change Communication Program. We talked about how, whenever we see rural sanitation programs carefully evaluated, again and again we see only a small effect on reduced open defecation, maybe a few percentage points. This is hard for everybody, so testing creative solutions is necessary — which is exactly what Arghyam is doing.
Maybe you work with an organization trying something new to make a big dent in rural open defecation? We would love to learn from you, too, and to work together to carefully measure the effects of your program. Be in touch!
We know from work by people like my friend Jeff Hammer, a professor at Princeton, that there is a lot that isn’t working week about public health care in India. (On absenteeism, see here. On performance, see here.) I got a reminder of how bad things are when I was talking to a 17 year old girl from rural UP about her experience with a public dentist and doctor. Just as an FYI, the story in this blog post happened two months ago, and I am only now getting around to writing about it.
The girl had a fever, and pain in her teeth from several cavities. She was complaining other symptoms too, some swelling, and general malaise. I’m not surprised that she feels bad much of the time; although she is not very poor by UP standards, she lives in tough conditions, and her diet is quite poor.
To try to get some relief for her ailments, she first went to a public dentist, who wanted to pull out the offending teeth. Understandably, the young woman did not want her teeth pulled—she’s only 17 and she needs those teeth for a good long time. So, instead of filling her cavities, she told me, the dentist prescribed medicine. I asked to see the medicine that had been prescribed. Most of these drugs were given to her at the public hospital, some she purchased from the nearby medical store. Here is a list of things that the dentist prescribed:
- amoxicillin (a common antibiotic)
- aspirin (a pain killer)
- alprazolam (a drug used to treat anxiety and panic disorder)
- gentamicin injection (a serious antibiotic with potentially serious side effects)
- diclofenac sodium injection (non-steroidal anti-inflammatory drug)
Thinking that the dentist had likely prescribed medicine only for her dental problems, she went next door to the public doctor, and told him about her other ailments. He did not ask any follow up questions, including what medicine she was already taking. Instead, he gave her a prescription for:
- metronidazole (a drug which is antibiotic, amebocidal, and anti-protazoal)
- alumina, magnesia & simethicone (anti-acid and anti-flatuent)
- cetirizine hydrochloride (antihistamine, used to treat respiratory allergies)
- amoxicillin (now she has a double dose of amoxicillin)
As before, she was able to get most of these drugs for free at the public hospital. But, since she can’t read very well in English, she did not know what the drugs are meant to treat, when to take them, and how much to take at a time.
The fact that the girl in this story was given so many medications, without any tests, verbal diagnoses, or counseling about how to take the drugs is quite worrisome. While it is true that the widespread availability and affordability of drugs in rural India, particularly antibiotics, has probably saved lives, this story suggests that health planners should also consider how overuse and abuse of drugs can have a negative impact on people’s lives. Many people likely experience negative side-effects of unnecessary medication, or of medication taken improperly, and evidence suggests that anti-biotic resistance is likely to be a big problem in the near future, if it is not already. And, of course, people like this girl probably don’t get as well as they could as fast as they could when they take medicines in a haphazard way.