While attending Sunday church services in May 2009, Dr. George Tiller, an abortion provider in Wichita, Kansas, was assassinated by an antiabortion extremist. The doctor’s murder led shortly to the closing of his clinic, Women’s Health Care Services (WHCS), which had been the best known of the handful of U.S. facilities to openly provide abortions at 24 weeks of gestation or later for women with serious health conditions and those carrying fetuses with severe or lethal anomalies. One of the most polarizing symbols of the U.S. abortion conflict, Dr. Tiller was reviled by abortion opponents.* Among abortion rights supporters, and especially among his colleagues in the close-knit abortion provider community, Dr. Tiller was a beloved hero, legendary for the kindness and compassion he extended to desperate women who came to him from all over the United States and abroad.
Dr. Tiller’s murder and the closing of his clinic brought renewed national attention to the problems facing women who need abortions late in pregnancy. Fewer than 2% of the 1.2 million abortions performed each year in the United States occur after 20 weeks of gestation.1 An unknown number occur after 24 weeks; in most states, such procedures are permitted only under highly restricted circumstances. At the time of Dr. Tiller’s death, only two or three other clinics were known to openly provide third-trimester procedures for qualifying women. Some hospitals provide these services on a case-by-case basis for patients of attending physicians, but the fact that WHCS served women from all over the country indicates that many women had difficulty finding the care they needed close to home.
WHCS’s closure raised important public health concerns; chief among these was what would become of women carrying wanted pregnancies that go horribly wrong late in pregnancy. For abortion providers wishing to offer similar specialized abortion care, and for scholars of the nation’s longstanding abortion conflict, the closure raises other important questions: What services were developed for this unique segment of abortion patients? How did staff cope with working in a facility that was continually under attack by antiabortion activists?
This report draws on interviews the author conducted with seven former WHCS staff members to address these questions. Open-ended group interviews took place in Wichita in December 2009. The author made follow-up queries by e-mail and phone. The institutional review board of the University of California, San Francisco, approved the project.
The focus here is on the carefully choreographed experience of women who qualified for abortions after 24 weeks’ gestation because of fetal indication—that is, their fetuses had anomalies such as anencephaly (the absence of a large part of the brain and skull) or trisomy 13 (a genetic disorder characterized by multiple abnormalities, which typically leads to death within the first month of life). According to staff, Dr. Tiller devoted much thought to the particular care needed by fetal indication patients, and he refined his approach over many years. These patients made up about 15–20% of the WHCS caseload. (Of the remaining patients, about half sought first-trimester abortions, and half either sought second-trimester abortions or came for later abortions because of "maternal indications"—serious physical or mental health conditions, such as cancer or pregnancy resulting from incest.)
First Phone Contact
Some women learned about Dr. Tiller’s practice after finding out they were too advanced in pregnancy to obtain an abortion from a local provider. Others were referred by genetic counselors they had consulted after learning of a fetal anomaly. Some women, either in the care of physicians opposed to abortion or having no regular physician, found WHCS on their own after searching the Internet.
However women learned of WHCS, their first contact with the clinic was by phone. The clinic’s phone counselors were trained to carefully screen for those who would qualify under Kansas’s strict guidelines for third-trimester procedures,† and prospective patients or their physicians were asked to fax documentation of the diagnosis. Those who were accepted as fetal indication patients were told to prepare for a 4–5-day visit, which typically began on a Tuesday. Interwoven with information on hotels and driving instructions were cautions about the protesters the patients could expect to encounter upon arrival.
Day 1: First Experiences at the Clinic
The events of the first day consisted of medical procedures and activities geared toward helping the patient psychologically prepare for the abortion. After checking in, patients, typically accompanied by spouses or other relatives, would watch a video made by Dr. Tiller describing what to anticipate during their several days’ stay in Wichita, including the details of the abortion procedure. (At WHCS, procedures performed late in pregnancy were done by induction, defined in a leading medical textbook as "the termination of pregnancy by stimulation of labor-like contractions that cause eventual expulsion of the fetus and placenta from the uterine cavity."2) Notably, fetal indication patients watched the video as a group. As staff explained, having patients bond with each other throughout their clinic stay was a central component of Dr. Tiller’s approach. "Doctor [as Dr. Tiller was invariably referred to by staff] felt that no one else could understand them as well as others in the same situation," said one staff member.
Once the video was over, Dr. Tiller met with the group, which typically consisted of 6–12 people. He prepared for this meeting, as a staff member said, by doing his "homework": Over the weekend preceding the arrival of a new cohort of fetal indication patients, he read the women’s files carefully, learning their names, the names of those accompanying them and their hometowns. In a blog post, the husband of one patient said of that first encounter:
"Dr. Tiller had an understanding of [our] pain, perhaps better than anyone who has never gone through it personally. As a doctor he was up-front about everything he was about to do and everything we needed to do to make things go well. When we arrived, he sat all four couples down and told us everything that was going to happen. He showed us the instruments he was going to use. He told us how the drugs would make the women feel. He told them flat out that it was going to hurt and she needed to be ready.… He also asked about us. He wanted to know who we were, what we did, and how we lived as couples and families."3
After this group meeting, Dr. Tiller met privately with each woman, couple or family to answer questions. The first day then proceeded with lab work and a meeting with a second physician, who, as required by Kansas law, would affirm patients’ eligibility for a post–24-week abortion. Then patients underwent what staff considered one of the most emotionally difficult experiences of their stay at WHCS: an ultrasound followed by an injection of digoxin, a heart medicine, administered in a dose that causes fetal demise without affecting the mother. At this time, patients were sedated with Versed, a drug that relieves anxiety and causes some memory loss, and Dr. Tiller inserted laminaria to gradually dilate the cervix in preparation for the induced labor that would follow in the next 48 hours or so.
The fetal indication patients then had lunch together in the clinic. Dr. Tiller often joined them if he was available. "For Doctor, having a meal together was a connection," one staff member explained. After lunch, Dr. Tiller and the staff chaplain convened a "support and healing group," at which participants were urged to share their stories. The bonding among patients intensified during this meeting, according to staff. As a nurse who was often present at these meetings put it, "A patient would begin to talk, and you could just see that all the other patients would be thinking, ‘Wow! Her story is almost like mine.’" A Latina staff member hired as a Spanish translator told a moving story of a patient who spoke no English and listened quietly to the others: "She sensed the empathy that was occurring among the others in the room and whispered to me that she wanted to tell her story…and proceeded to do so in Spanish."
At this meeting, Dr. Tiller asked patients what kind of support they had back home and what they had told others about their trip to Kansas. Such concerns were especially pertinent to patients who had children, whom they had had to leave with relatives or friends. Staff told of a handout that Dr. Tiller had prepared to help patients navigate difficult conversations, colloquially referred to as the "nosey people paper." A staff member summarized Dr. Tiller’s recommended response to those inquiring why someone who had been visibly pregnant no longer was: "The baby was sick. We went for testing. The baby didn’t make it. It’s hard for me to talk about it right now."
Patients at this meeting were also given written information on "baby plans"‡—the options available to them after their abortion. They were asked to consider, for example, whether they wished to see and hold their baby after delivery and whether they wanted pictures, blankets and footprints as keepsakes. They were also asked to contemplate whether they wanted a baptism or other religious ceremony, and whether they wished to have their baby’s ashes shipped to them after cremation at WHCS.
WHCS offered patients an array of options for religious services. Dr. Tiller was a deeply spiritual person, and his clinic pioneered the incorporation of religious elements into abortion care. The chaplain on staff, a Protestant minister, was available to tailor services for Christian and nonaffiliated patients. The clinic also forged relationships with local rabbis and an imam in a neighboring county. One staff member recalled, "When we had a Muslim patient, I’d call Mr. S, and he’d come over and talk to the patients, and make sure that I’d wrap the baby’s body in linen for the funeral service he’d conduct."
As patients left the clinic on the first day, they were instructed to go to a pharmacy to pick up various medications. Typically, they then drove to their hotels. Many, according to staff, made dinner plans with other patients they had met that day.
Day 2: Further Preparations
The second day of fetal indication patients’ stay (typically a Wednesday) continued with a similar mixture of medical procedures and emotional support activities. The women had laminaria removed and new ones inserted, and received another ultrasound. Medical personnel checked to ensure that the digoxin injection had caused fetal demise. At another group meeting, Dr. Tiller and the head nurse went over the mechanics of the day of delivery.
The patients then had another private meeting with Dr. Tiller and the chaplain, at which point they filled out a form declaring their preferences for the "baby plan."
Days 3 and 4: Delivery
Most fetal indication patients were expected to deliver on Thursday, day three of their stay, or Friday, day four. They were instructed to fast as of midnight on Thursday. Upon a patient’s arrival at the clinic on Thursday morning, a nurse would check her cervix and insert new laminaria. The long-time head nurse was very adept at predicting the time of delivery; women who were expected to deliver within the next several hours were started on intravenous antibiotics and sedation, and were given misoprostol, which started contractions. Then, as this nurse said, "We just waited."
While waiting for labor to begin, patients were supported by partners and relatives, and Dr. Tiller and other staff periodically stopped by to check on their progress and offer encouragement. "He [Dr. Tiller] would spend as much time as he could [with the fetal indication patients], rubbing their backs, chitchatting about different things," said one nurse. Staff reported that Dr. Tiller firmly believed that "a woman’s body knows best," and patients were not given additional medication to hasten delivery. While they waited in the labor suite, women expressed support to each other. As the nurse remarked, "It was always amazing to me how much they cared about the other person … how fast people bond when they’re going through a crisis together."
If it looked likely that a woman was going to deliver during the night, arrangements were made for her to stay overnight at the clinic, where a staff member was in attendance.
Day 4 or 5: Viewing the Baby and Saying Good-Bye
Because patients were sedated during the induction, Dr. Tiller’s custom was to show the baby to parents who wished a viewing (and most did) the next day. This typically occurred after the woman’s final postdelivery checkup, in the clinic’s Quiet Room. According to staff, "The room, we set it up before they went in there…. We’d light candles and have soft lighting." Dr. Tiller, accompanied by the chaplain and often by the head nurse, would tell the parents what to expect (such as babies with organs outside their bodies, misshapen heads and other potentially disturbing sights) and ask them if they wanted to see and hold the baby. If they did, the baby would be brought in wrapped in a blanket. "Sometimes we would hold hands and say a prayer with the parents," recalled one nurse. Parents were then offered time alone with their baby and were encouraged to take as long as they wished.
Typically, the patients and those accompanying them would leave for the airport immediately after seeing their baby, stopping only for a quick, and often tearful, good-bye to staff. Staff acknowledged that some patients had a difficult time leaving the supportive environment of the clinic for the impersonal atmosphere of the airport. Staff expressed particular compassion for childless women and couples. "The ones without kids, those are the ones that hit me the most…. Often, they had their nursery all set up," said one.
WHCS was one of the most targeted abortion clinics in the country. Indeed, the militant antiabortion group Operation Rescue moved its headquarters to Wichita from California in 2002 expressly to force the clinic’s closure. Protesters—who included statewide organizations such as Kansas Citizens for Life, smaller church groups and individuals—made their presence felt in three ways: by protesting at the clinic itself, gathering at the homes of Dr. Tiller and his staff, and pressuring local merchants to boycott the clinic.
Patients arriving at the clinic typically encountered noisy protesters, many of whom had bullhorns or waved huge placards with grotesque pictures that purportedly depicted aborted fetuses. Protesters were at the clinic virtually every day, in groups that generally ranged in size from a half-dozen to more than 10 times that. Several hundred would arrive on special occasions, such as the January 22 anniversary of Roe v. Wade. The protesters sometimes threw themselves in front of arriving cars. They would take pictures of patients’ license plates and, when possible, of patients themselves. In response, some patients wore wigs and sunglasses, while others pulled coats over their heads before walking to the clinic doors. When patients left the clinic, according to staff, protesters again shouted at them and attempted to take photographs. When staff were asked what they thought was the most challenging part of the experience at WHCS for patients, they immediately responded "the protesters."
Employing a common tactic, antiabortion forces purchased a property adjacent to WHCS and opened a so-called crisis pregnancy center. This center attempted to lure confused abortion patients to its doors to counsel them against the procedure. "They would zero in on the Asian and Spanish-speaking patients," one staff member recalled. Observing this through the window, staff would dispatch the WHCS security guard to bring the rattled patients to their intended destination.
Periodically, WHCS experienced serious vandalism and violence. Such incidents included a firebombing in 1986; the Summer of Mercy in 1991—a months-long siege of the clinic and Dr. Tiller’s home led by Operation Rescue, which was attended by antiabortion protesters from all over the country and resulted in hundreds of arrests;4 and, in 1993, the shooting of Dr. Tiller in both arms by a member of the extremist Army of God. (Dr. Tiller was not seriously wounded in that shooting, and he returned to the clinic the next day.)
Although Dr. Tiller was hardly alone among abortion providers in being targeted by extremists, it was somewhat unusual that nearly all WHCS staff members were targeted as well. Use of this tactic escalated after Operation Rescue moved to Wichita. Staff members said that antiabortion organizations circulated flyers with their names, addresses, phone numbers and pictures, and sent postcards to their neighbors, urging them to demand that WHCS employees quit their jobs. Most upsetting—particularly to those with young children—were demonstrations at staff homes, replete with what one clinic employee called "the nasty truck with the pictures of fetuses."
Dr. Tiller was also subject to repeated legal actions by various political opponents. Notably, the former attorney general of Kansas, Phill Kline, made it a personal crusade to shut down WHCS.§ Operation Rescue leaders also filed numerous legal complaints against Dr. Tiller, taking advantage of an 1887 law, unique to Kansas, that allowed grand juries to be impaneled on the basis of citizen petitions. Dr. Tiller won all these court battles. In his last trial, in March 2009, the jury acquitted Dr. Tiller in less than 45 minutes, dismissing accusations that he had violated the second physician requirement for post–24-week abortions.5 Nevertheless, the clinic manager reported, these frequent legal battles imposed a considerable emotional strain on both Dr. Tiller and his staff.
On a day-to-day basis, one of the most difficult things for staff to manage was the boycott of the clinic by local businesses, an action engineered by Operation Rescue and other groups. Protesters photographed the license plates of all vehicles that entered the premises and maintained a list on the Operation Rescue Web site of local establishments that did business with the clinic. In many cases, this intimidation worked. Staff reported that numerous local establishments abruptly ended long-standing business relationships with WHCS.
As a result, many services to which medical providers normally would not give a second thought became problems for the resourceful staff to solve. For example, the pizza restaurant that for years had delivered the lunch served to patients suddenly refused to continue driving onto clinic grounds. Similarly, the hotel chain to which WHCS had long sent its fetal indication patients in return for reduced rates canceled this arrangement because of pressures brought on the chain’s national office. (The termination of this arrangement may also have been due to protesters’ periodically showing up in the hotel and putting antiabortion material under other guests’ doors.) Furthermore, of the three cab companies in Wichita, only one agreed to provide services for WHCS patients, and even with this company, there were sometimes problems. One of the company’s part-time drivers was a Catholic priest, who staff said harangued the patients. "So we had to call the company and say, ‘You have to provide a driver that will not hassle our patients.’" Even then, problems with cab drivers’ behavior did not end: Some drivers—whether out of fear of the protesters or in sympathy with them—would not follow instructions to take patients into the clinic’s back private parking lot, instead leaving them in the street, where they would have to make their way past screaming protesters to reach the clinic doors.
Arguably the most worrisome outcome of the boycott occurred when the company that had long provided trash hauling for the clinic called to say, as the clinic manager put it, "they were no longer interested in doing business with us." She frantically called other local companies and finally found one willing to provide this service, "but with a ‘but’": The new company would come to the clinic only in the middle of the night, which necessitated additional security arrangements to enable the truck to enter the secured parking lot. The clinic manager explained, "They drove an unmarked truck and had an unmarked bin, so nobody would know who they were."
WHCS STAFF: STAYING THE COURSE
The WHCS staff had to deal with daily threats to the personal safety of their patients and themselves, repeated politically inspired lawsuits that put clinic operations at risk and elaborate negotiations with businesses fearful of being associated with the clinic—in addition to attending to fetal indication patients at a time of immense grief and caring for the other patients who came to WHCS. Despite these challenges, some staff had worked at WHCS for many years—the head nurse for more than 30 years, and the clinic manager for 14. And all staff made it clear that they were not only devastated by Dr. Tiller’s death, but deeply saddened to have lost work they loved. How did the WHCS employees cope with such a turbulent workplace?
In simplest terms, the staff’s commitment to this challenging work cannot be separated from their evident devotion to Dr. Tiller and their belief in the importance of what he had created at WHCS. Tiller often referred to the mission of the clinic as "saving women’s lives,"6 and the staff clearly accepted this framing of their work. One recalled, "Doctor used to say, ‘We could all be working somewhere else, and if we are working here, it is for a reason.’"
By all accounts, Dr. Tiller was a beloved employer, who made clear to his staff how much he valued their work. One physician described how, when she started at the clinic, Dr. Tiller would observe her while she performed abortions for fetal indication patients: "He would see what was good about your technique, and he would encourage it." She went on to recount how her new boss told her he modified his own practice after noting her skill at getting patients to relax.
Dr. Tiller also made it clear that he recognized the unusual sacrifices that working at WHCS entailed. For example, staff received additional "combat pay," as the doctor called it, when they were targeted at home by protesters. Moreover, Dr. Tiller frequently sought opportunities to celebrate his employees and their work. On one memorable occasion, Dr. Tiller organized a party in honor of an elderly employee who worked as a "hand-holder" for patients. Recognizing that the woman had never before worked outside the home, he presented her with a blown-up version of her first paycheck. Occasionally, in a political gesture that was especially meaningful to the staff, the clinic offered abortions at no cost to celebrate the anniversary of Roe v. Wade.
Working at WHCS led staff to identify strongly with the national abortion rights movement and, in particular, with their abortion provider colleagues. Abortion facilities across the country were regularly in touch with the clinic, where they periodically sent difficult cases. Staff who sometimes accompanied Dr. Tiller to national conferences of abortion providers reported feeling particularly appreciated by this community because of the special efforts WHCS made to accommodate hardship cases, such as by caring for incest victims (some as young as nine years old) and performing abortions at reduced or no cost.
Similarly, the very intensity of the opposition in Wichita led staff to feel especially gratified by demonstrations of local support. After the 1991 Summer of Mercy siege, for example, staff reported being deeply touched that community groups raised money to build a fence around the clinic. The dismay staff felt about the boycotts only strengthened their appreciation of the mainly family-owned local businesses that stood by them. The show of support by neighbors, even self-identified "pro-lifers," after protesters came to staff homes, was particularly reassuring. One staff member recounted, "I don’t think any of us had problems with the neighbors after that…. I got a bouquet of flowers and a bunch of nice cards."
As noted earlier, Dr. Tiller was a highly spiritual person, and he periodically referred to the clinic’s work as a "ministry." Similarly, several staff—particularly those with the most emotionally challenging work—pointed to their own strong religious beliefs as having guided their work. "I felt I was doing the Lord’s work," said the staff member charged with readying the stillborn babies to be seen by their parents. In almost identical terms, the woman who prepared the babies’ bodies for cremation said, "God put me here to do this work." And the clinic chaplain, referring to the comfort she tried to give to grieving parents, recounted, "This was holy work we were doing here. We gave the parents the gift of not having to make their babies suffer."
Gratitude from patients, particularly fetal indication patients, was also was a major factor in sustaining staff morale. One staff member said, "I have never worked for any physician where there was that kind of love and appreciation [from patients]…. They really felt like they had their lives back, that this was a place of healing for them." The walls of the clinic were papered with thank-you letters from former patients. The staff were also aware of a Web site, Kansas Stories, which posted former patients’ descriptions of their experiences.7 Expressing sentiments typical of the site’s contributors, one posting read, "We are forever grateful to the Women’s Health Center, the amazing doctor and all the staff for being our heaven when we were living in hell."
Finally, a sense of pride and professionalism sustained the staff’s commitment to their highly demanding jobs. The clinic manager, recounting the ways she and her colleagues surmounted the obstacles put forward by their opponents, said, "We were survivors. We had to be."
The history of WHCS is unique in several respects. No other clinic in the United States has been such a powerful symbol for both abortion opponents and supporters. Nor has any other facility been subject to such a sustained level of protest.6 And although the majority of abortion facilities experience some form of harassment, none have received the volume of violent threats that WHCS did. In April 2011, nearly two years after Dr. Tiller’s murder, the FBI released documents that revealed that the agency had investigated "numerous death threats" against the doctor since the 1990s.8 But, paradoxically, the very intensity of this opposition contributed to both Dr. Tiller’s and his staff’s resolve to continue with their work.
Given that Republican gains in the 2010 elections have led to an explosion of laws, at both the federal and the state levels, seeking to further restrict abortion at all stages,9 it is difficult to be optimistic about the availability of abortions for those who need them late in pregnancy. Nevertheless, in response to the closing of WHCS, a number of facilities across the country have extended their services to include abortions after 24 weeks’ gestation under legally permitted circumstances. Most notably, a clinic in New Mexico, Southwestern Women’s Options, hired two former WHCS physicians and has begun to offer post–24-week abortions on a "case-by-case basis," incorporating a modified version of the group experience for fetal indication patients pioneered in Wichita. It remains to be seen whether this clinic can avoid the polarization that characterized WHCS.
*Before Dr. Tiller’s murder, Bill O’Reilly often referred to him as “Tiller the Killer” on his Fox News television show (source: Winant G, O’Reilly’s campaign against murdered doctor, Salon.com, May 31, 2009, <http://www.salon.com/news/feature/2009/05/31/tiller>, accessed Apr. 15, 2011).
†Kansas law permits abortions after 24 weeks on the grounds of lethal or serious fetal anomalies and threats to the pregnant woman’s life or health. The law also permits abortions for reasons of mental health, which led WHCS to provide abortions for those deemed suicidal and those whose pregnancy had resulted from rape or incest. Abortions occurring after 24 weeks must be approved by a physician with whom the abortion provider has no financial relationship. As of summer 2011, however, there are no providers of post–24-week abortions in Kansas; indeed, the three remaining abortion-providing facilities are threatened with closure because of new licensing requirements (source: Sulzberger A and Davey M, New law in Kansas seen as a threat to abortions, New York Times, June 24, 2011, <http://www.nytimes.com/2011/06/25/us/25kansas.html?_r=1&scp=1&sq=abortion%20Kansas&st=cse>, accessed June 28, 2011).
‡For fetal indication patients, staff used the term “baby,” rather than “fetus,” reflecting these patients’ preferences. The word “baby” was not typically used with other abortion patients at WHCS; among other women, the most common term was “pregnancy.”
§As of summer 2011, Kline was facing disbarment as a result of disciplinary hearings based on charges that he misled judges and mishandled evidence in his investigation of WHCS (source: Cooper B, Round one of Kline ethics hearing winds up, Kansas City Star, Mar. 3, 2011, p. A6).
1. Guttmacher Institute, Facts on induced abortion in the United States, In Brief, 2011, <http://www.guttmacher.org/pubs/fb_induced_abortion.html>, accessed Apr. 15, 2011.
2. Paul M et al., Management of Unintended and Abnormal Pregnancy: Comprehensive Abortion Care, West Sussex, UK: Blackwell Publishing, 2009, p. 178.
3. Young D, Eulogy for Dr. George Tiller, Rabbi Young’s Blog, 2009, <http://rabbiyoung.blogspot.com/2009/06/eulogy-for-dr-george-tiller.html>, accessed Jan. 10, 2011.
4. Risen J and Thomas JL, Wrath of Angels: The American Abortion War, New York: Basic Books, 1998, pp. 324–333.
5. Stumpe J, Jurors acquit Kansas doctor in a late-term abortion case, New York Times, Mar. 27, 2009, <http://www.nytimes.com/2009/03/28/us/28abortion.html>, accessed Mar. 1, 2011.
6. Barstow D, An abortion battle, fought to the death, New York Times, July 26, 2009, <http://www.nytimes.com/2009/07/26/us/26tiller.html?ref=georgertiller>, accessed June 27, 2011.
7. A heartbreaking choice, Kansas Stories, 2010, <www.aheartbreakingchoice.com/kansasstories>, accessed Mar. 7, 2011.
8. Hegeman R, Pages detail FBI probes into Tiller death threats, Wichita Eagle, Apr. 6, 2011, <http://www.kansas.com/2011/04/06/1795675/pages-detail-fbi-probes-into-tiller.html>, accessed Apr. 15, 2011.
9. Guttmacher Institute, State legislative trends: hostility to abortion rights increases, 2001, news release, Apr. 12, 2011, <http://www.guttmacher.org/media/inthenews/2011/04/12/index.html>, accessed May 9, 2011.
Carole Joffe is professor, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco.
The author thanks Tracy Weitz and Shelley Sella for their helpful comments on a draft of this special report, and Michaela Ferrari and Elisette Weiss for their excellent research assistance.