Why they killed: the micro-politics of Rwanda’s genocide

by Barbara Miller

One of the most unusual aspects of Rwanda’s genocide that continues to shock and puzzle, 13 years after the killings, is the high level of civilian participation. Other distinguishing characteristics are the speed of the civilian mobilization, the extensive geographic spread of the  killing throughout the country, the velocity of the violence, and the high percentage of the victim group killed.

Dr. Omar McDoom, Lecturer (Assistant Professor) in Political Science at the London School of Economics, spoke about these issues on September 17 in the Elliott School of International Affairs at the George Washington University. His talk was the first in the 2009-2010 CIGA Seminar Series. CIGA is the Elliott School’s Culture in Global Affairs Research and Policy Program.

McDoom spent a year doing intensive fieldwork in Rwanda including conducting over 300 interviews with two groups of Rwandans: those who had killed (they were in prison at the time of the interviews) and those who were related to people who had been killed. He also uses population census data to estimate the number of victims and GPS data to locate regional patterns of killing.

In his talk, McDoom linked macro and micro levels in explaining why the Rwandan genocide occurred and its distinctive patterns. For example, he ties the unusual strength of the Rwandan state to the speed and extensive of the violence. Rwanda, in contrast to many other post-colonial states, had enduring boundaries and longstanding coherence as a “state.” A strong state can accomplish good things more effectively than a weak state and also bad things more effectively than a weak state.

At the micro-level, McDoom’s interviews reveal that killers cluster in families. That is, if one brother had killed, it was likely that his brother would also kill. GPS data indicate regional patterns. Killings were more frequent in densely populated areas. Those who lived in remote regions were less vulnerable.

McDoom is not a “political ethnographer” in the sense of someone who learns the local language and lives with the local people for a long time doing everyday things with them. While he did spend a substantial period of time in Rwanda, he had to use an interpreter for his interviews with killers and victims. And, of course, he was not in Rwanda during the genocide doing “participant observation.” Nonetheless, it is clear that his research benefits immensely from his interviews with many people who were involved and in recording and analyzing their views. If there were an anthropological award for a non-anthropologist, I would nominate McDoom for consideration.

McDoom’s MA training in International Development Studies at GW and his exposure to anthropology during that time likely had a formative influence on how he defines research questions and goes about finding data to answer them. His PhD from LSE is also in Development Studies. Given his postgraduate credentials (that also include a law degree), I am not quite sure how he recrafted himself to look enough like a political scientist to be hired in the Political Science Department at LSE in a regular faculty line. It is, though, a hopeful sign for the discipline. And a hopeful sign for genocide studies and genocide prevention.

Photo by Anne Wernikoff, from the GW Hatchet.

Anthro in the news 10/12/09

• Too Poor to Do the Right Thing

Many people in the United States can no longer afford to bury or cremate their dead loved ones due to the so-called economic downturn. According to an article in the New York Times, “Coroners and medical examiners across the country are reporting spikes in the number of unclaimed bodies and indigent burials with states, counties, and private funeral homes having to foot the bill when families cannot.” Oregon has seen a 50 percent increase in unclaimed bodies.

In Tennessee, unclaimed remains are donated to the Forensic Anthropological Research Center, also known as the “Body Farm.” The bodies are buried and students use them to study patterns of decomposition over time. This year, the Center received more bodies than it could handle and was forced to halt its donation program.

There is no good news here.

• Son of an Anthropologist Wins Nobel Peace Prize

On a brighter note, President Barack Obama was awarded the Nobel Peace Prize this week, a happening that was widely covered in the mainstream media though, as far as I can tell, no one so far has connected his peace-making efforts to the potential influence of his mother, Ann Dunham, who was a cultural anthropologist.

A BBC documentary, “Dreams from My Mother,” provides insights into the life of Stanley Ann Dunham (so-named because of her parents’ wish to have a son). It shows how, after her second divorce, she moved to Yogyakarta, in Java, and began her lifelong study of indigenous crafts industries. Later she was admitted to the PhD program at the University of Hawai’i where she pursued the archaeology and cultural anthropology of blacksmithing in Java. Moving beyond her academic studies, in order to help people in these industries, she constructed a model of micro-financing which is now the standard in Indonesia. She generated support for her work from the Ford Foundation and the World Bank to help poor rural people launch small businesses.

Ann Dunham was an unconventional woman: a devoted mother, pioneering scholar, and applied anthropologist working on behalf of the poor. Is her importance, as an anthropologist and humanitarian activist, in the achievements of her son getting the attention it deserves?

Critical medical anthropology gone mild?

by Barbara Miller

Merrill Singer’s 1989 article “The Coming of Age of Critical Medical Anthropology” is a landmark contribution in shaping the direction of critical medical anthropology. In its conclusion, he lists seven tasks that I paraphrase as:

  1. Contributing to the political economy of health.
  2. Analyzing micro-macro relations.
  3. Studying power relations at global and local levels.
  4. Clarifying the meaning of “critical medical anthropology.”
  5. Studying biomedicine and how it links the capitalist and working classes.
  6. Examining the specific relationships between biomedicine and capitalism.
  7. Conducting fieldwork on socialist health systems.
  8. Contributing to the creation of a new medical system that is counter-hegemonic.

Every year, I assign this article, along with other early writings in critical medical anthropology, for the first week of my graduate medical anthropology seminar. It never fails to generate good class discussion.

In recent years, Singer has become a veritable publishing machine, turning out articles, chapters, and co-authored or co-edited books at an amazing rate. He is now an Associate Editor of the journal Medical Anthropology. As testimony to his many professional and academic achievements, Singer has received major awards including the Rudolph Virchow Prize, the George Foster Memorial Award for Practicing Anthropology, the AIDS and Anthropology Paper Prize, and the Prize for Distinguished Achievement in the Critical Study of North America. After working for many years with the Hispanic Health Council in Hartford, he is now professor of anthropology at the University of Connecticut and affiliated with Yale University’s Center for Interdisciplinary Research on AIDS.

Without doubt, Merrill Singer is a pillar of medical anthropology.

So I was delighted to see an essay by him in Medical Anthropology entitled “Pathogens Gone Wild? Medical Anthropology and the ‘Swine Flu’ Pandemic.” (By the way, Singer invented and mainstreamed the term “pandemic”). In the early part of the article, true to form, Singer talks about the “macropolitics” and “micropolitics” of epidemics and anxiety-producing “emerging diseases.” He points to the causal role of anthropogenic global environmental changes in emerging diseases and how such changes differentially affect the poor. He makes a pitch for medical anthropology as being of particular value in understanding modern epidemics because of its attention to biosocial and biopolitical processes and its grounded study of the social factors of disease. All vintage Singer.

Turning to H1N1 specifically, he provides a list of tasks for medical anthropology:

  1. Field monitoring of the pandemic as a biosocial phenomenon.
  2. Assessment of the biosocial origins and ongoing social influences of the pandemic.
  3. Involvement that is research-based and culturally-informed in public health efforts.

Under point #1, he includes important topics such as mapping the “geography of blame” and critical analysis of social stigma and of media overreaction. Under point #2, he urges anthropologists to probe possible connections between the H1N1 outbreak and industrial farm animal production (IFAP) including improper disposal of animal waste. Here he makes a pitch for syndemics in examining human-animal linkages as routes of transmission. His discussion of point #3 receives only one paragraph in which he says that anthropologists can contribute to health care programs in several ways including:  formative research for program design and involvement in program implementation, management, and evaluation, and in public education programs. This paragraph reads as if it came from an applied anthropology cookbook–nothing Singerish here.

The three points, however, stand as valid even if the last is weakly developed. But the article is not up to the standard set in his 1989 article. First, at the global level, the role of the pharmaceutical industry and the likely huge profits being reaped from the sale of the vaccine must be brought in to the picture of H1N1 to make it more complete. Second, the vaccine links to another missing topic: medical anthropologists should do local-level research to about people’s refusal to get the vaccine, including health care providers. This topic will provide insights into people’s fear of the unknown side-effects of the vaccine and their resistance to the bioestablishment which promotes the vaccine as a moral imperative.

Compared to the Merrill Singer who wrote the 1989 article, the Merrill Singer of 2009 has gone mild. In his recent essay, he is right to finger capitalist agriculture but errant in ignoring pharmaceutical capitalism. Furthermore, the new Merrill Singer seems to have abandoned his 1989 vision of anthropology contributing to a “counter-hegemonic” health system.

My heartfelt congratulations to Merrill Singer for all his accomplishments. At the same time, I miss the Merrill of twenty years ago.

Photo, “Influenza Virus H1N1 HA Protein”, on Flickr via Creative Commons.

Anthro in the News 10/5/09

• One very expensive lady

Front-page articles in many newspapers and other outlets, including the New York Times and the Washington Post, heralded the long-awaited publication of research findings about “Ardi,” a 4.4 million year old hominin fossil discovered in Aramis, Ethiopia in 1992-1993 and preliminarily described in 1994. Tim White, paleontologist and Professor of Integrative Biology at the University of California, discovered the first fossil evidence of Ardipithecus ramidus and has headed a comprehensive research project in the area since then to accumulate more fossil and contextual evidence. He is the lead author or a contributing author of 11 papers  about Ardi published in a special issue of Science. The impressive scope of the articles, from botany and other aspects of the habitat to discussion of her (the researchers seem confident of Ardi’s gender) skull, teeth, forelimbs, and locomotion, may help explain the very long time that it took for these reports to appear. The “public” in the US may be little aware that their tax dollars funded most of the research (8 grants from the National Science Foundation), and they likely have not been waiting with baited breath for the findings, though many paleoanthropologists have been. I hope the public will appreciate the importance of the studies and do not fall into the trap of believing wacko headlines on the Internet about how Ardi “proves that man is not descended from apes.” White et al. owe it to the public to get the message out widely and soon.

• Banking on ethnography

An ethnography of Wall Street banking is touted as required reading for business students by the capital markets editor of the Financial Times, Gillian Tett. Tett, who earned a PhD in social anthropology before becoming a journalist,  reviewed Karen Ho’s book, Liquidated: An Ethnography of Wall Street in the FT. Tett admits to being embarrassed when bankers asked her about her academic past because they  considered anthropology to be “hippy” and lacking the status of economics and other “hard” sciences. “Not anymore” she says, since the economic crisis, which has shaken bankers’ faith in their economic models and demonstrated the need for a grasp of “cultural dynamics” in understanding how finance works. I hope she’s right. I haven’t witnessed much shaken faith on this side of the Atlantic. Turning to Liquidated: the author, Karen Ho teaches in the Anthropology Department at the University of Minnesota. Before becoming an anthropology professor, she was a banker with a Wall Street giant. Her fieldwork reveals the “habitus” (from Pierre Bourdieu) of bankers and shows how bankers’ rhetoric of “shareholder values” and “free market capitalism” appears to them as “truth” but is actually part of a system full of contradictions and, overall, delusion.  Tett closes her review by saying, “I, for one, would vote that Ho’s account becomes mandatory reading on any MBA (or investment banking course).”

• Cooking is hot

Possibly the most reviewed anthropology book of 2009 is Richard Wrangham’s popular account of the role of cooking in human evolution, Catching Fire: How Cooking Made Us Human. by Richard Wrangham. In the latest of a spate of reviews,   FT writer Harry Eyres tells how he is totally won over by the book, joining the ranks of other  writers in the “mainstream media” who all seem to love the book. Wrangham, who is professor of biological anthropology at Harvard University, has found a hot topic and produced a readable account of it for nonspecialists.  As a strong non-fan of Wrangham’s earlier popular book (with Dale Peterson), Demonic Males, I am, however, trying to read Catching Fire with an open mind. So far, I am finding his evidence for the role of cooking in making us human more convincing than his evidence for a shared heritage with chimpanzees in explaining male violence.

• Anthropology of footwear

An essay in the Wall Street Journal’s livemit.com cites a 2008 study by Erik Trinkaus, professor of physical anthropology at Washington University in St. Louis, about the first “supportive footwear.” Anatomical evidence from the middle Upper Paleolithic in Europe indicates that the bones of little toes became much less strongly built during that period. This change suggests that human ancestors of the time were wearing some kind of supportive footwear. This research throws into question the claim that running barefoot is the most adaptive way for go, as is argued in Christopher McDougall’s controversial bestseller, Born to Run (see a related posting earlier in this blog).

[For more information, see Erik Trinkaus, Anatomical Evidence for Antiquity of Human Footwear Use” Journal of Archaeological Science 32: 1515-1526, 2005.]

The Tiwi are robbed again

If there were a Hall of Fame for the Most Cruel Colonizers of the World, Australia would have a prominent place. Early British settlers (“unsettlers” or displacers, more accurately) hunted the Tasmanians to near-extinction. None of the indigenous groups have been left unscathed. And today the cruelty  continues in new, more “civilized” guises such as economic development.

Editorialist Verlyn Klinkenberg reports on his findings from a recent visit to Melville Island, off the coast of the Northern Territory.  With neighboring Bathhurst Island, it makes up the Tiwi Islands, original home of the Tiwi people.  As his small plane flies over the island, he can see a 75,000 acre plantation of acacia trees.  It is a forestry project run by Great Southern Plantations, a company based in Perth. Acacia trees grow quickly and provide wood chops for the paper industry. The plantation was built on aboriginal reserves, in collaboration the Tiwi Land Council representing Tiwi “traditional owners.”  The goal was to create 300 jobs for Tiwi Islanders and lay the foundation for an enduring forest industry.

However, the company collapsed in May and the project is in receivership. Instead of the anticipated jobs and  income stream, there is desolation and increasing mistrust of Great Southern, the Northern Territory government, and the Tiwi Land Council.

Many Tiwi regret the clearing of the forest and many feel a sense of being robbed of their entitlements once again. They tried in good faith to work with outsiders to pursue economic goals that would help them maintain their self-determination. What seemed like a good investment was instead a high-risk gamble, and the Tiwi lost.

Somebody, however, made big money when the forest was cleared for the plantation. Moreover, the failed acacia plantation is not the only development disaster that has been foisted on the Tiwi Islands.

See some related blog commentary here.

Photo, “Changing Seasons”, of Australian acacia trees from Flickr via Creative Commons.

Anthro in the news 9/28/09

Ethnography Gains a Toehold in Political Science

An article entitled “Political Scientists Get Their Hands Dirty” in the Chronicle for Higher Education describes how some US political scientists are doing “political ethnography,” or fieldwork-based research involving long-term participant observation, the hallmark research method invented by cultural anthropologists. Edward Schatz is one of the “new” political ethnographers. He is the editor of a new book from the University of Chicago Press called Political Ethnography: What Immersion Contributes to the Study of Power. The book includes contributions from 16 scholars who argue that political scientists should take a serious lesson from cultural anthropology. That’s the good news. The bad news is this: Given the dominance in US political science of formal modeling and quantitative analysis, a political scientist who opts for an ethnographic approach and qualitative data is likely to be seen as far from the leading edge of the discipline and maybe even unworthy of full tribal membership when it comes to searches for tenure-line positions in academia. Perhaps, however, political ethnographers will be welcome in anthropology departments? Or will the anthropologists view them as less than anomalous and not unworthy of being full members of their tribe?

Gold Hoard a Treasure for Archaeologists in England

Related to the topic of disrespected methods: vindication for hobbyist “metal detectorists” came from an announcement of a major discovery in a field in Staffordshire, England, of 1,500 military- related pieces of gold and silver, some encrusted with gems. No longer the subject of mockery for his hobby, Terry Herbert, who discovered the hoard, will receive half its monetary value. Archaeologists are already involved in analyzing the find and its context. Tentative dating places it in the 7th century, a time of war between vying kings, plunder and fine metalwork devoted to the creation of beautiful objects for warriors.

David Vine on Engaging the Military

Inside Higher Ed carried an op-ed by cultural anthropologist David Vine, assistant professor at American University. Vine summarizes key aspects of the debate within US anthropology concerning anthropological collaboration with counterinsurgency efforts in Iraq and Afghanistan. He reports on the highlights of a recent two-day meeting at Brown University’s Watson Institute of International Studies convened by the newly founded Eisenhower Research Project for the Critical Study of Armed Forces and Militarization. Participants included anthropologists, historians, and others. They discussed US military spending, military checkpoints in Iraq, the increasing use of remote-controlled robots and other advanced technologies in war, the military’s role in the war on drugs, the militarization of the US border, “military wives” and “military families,” and how Hollywood and popular culture glorifies war. Vine concludes by stating his view that no military solution to the Taliban exists and that US foreign policy must move more firmly toward international cooperation rather than invasion as a strategy. He sees a crucial role for anthropologists and other social scientists working with the military and engaged citizens in advancing policy in this direction. Anthropologists and other social scientists, however, have typically distanced themselves from policy debates in international relations. So Vine urges them (us) to proceed in a new direction as well.

Evolutionary Anthropologists Link Sleep with Resistance to Infections across Species

An article in the New York Times on the relationship between the amount of sleep and the risk of catching a cold (yes, they are connected) mentioned related research by a team of evolutionary anthropologists (B.T. Preston, I. Capellini, P. McNamara, R. A. Barton, and C.L. Nunn) at the Max Planck Institute for Evolutionary Anthropology in Leipzig. Their comparative study of sleep patterns in many animal species demonstrates that the more members of a species sleep, the more resistance to infections they have. There’s a definite take-home message here.

American Anthropologist launches “Public Anthropology Reviews”

Request for Submission of Review Materials

AAA is pleased to announce the launch of “Public Anthropology Reviews,” a new review section in American Anthropologist.

Public Anthropology Reviews will highlight anthropological work principally aimed at non-academic audiences, including websites, blogs, white papers, journalistic articles, briefing reports, online videos, and multimedia presentations. The editors will also consider other traditional and innovative mechanisms for communicating anthropological research and concepts outside of academic realms and welcome suggestions. Please note that this review section will complement existing review sections and will therefore not review books, films or museum exhibits.

Editors: Melissa Checker (CUNY Queens C), Alaka Wali (Field Museum) and David Vine (American U)

They are now accepting submissions for materials to be reviewed in the June 2010 issue of AA. Please send inquiries, ideas and submissions of materials for review to: publicanthreviews@gmail.com

The purrfect solution?

by Barbara Miller

Cheetahs are major draws for the international tourist industry in southern African countries. In Namibia, home of one-fourth of the world’s population of cheetahs, tourists pay big money for the chance of a close-up look at these large cats. The cheetah population has been declining in recent decades, however, mainly due to being killed by farmers. The tourist industry therefore cannot guarantee a sighting to high-paying visitors.

In an article in the Financial Times, journalist Colin Barraclough describes his stay at the Okonjima Lodge in Namibia where a double room costs between US $250-1000 per night. The AfriCat Foundation, based at the Lodge, is a nonprofit organization established to help protect Namibia’s big cats. Barraclough saw pens where injured and orphaned cats are housed in preparation for their return to the wild. While this effort may warm the heart of animal lovers, it’s not done out of altruistic feelings about the animals but to protect profits from high-end tourism.

A major challenge in cheetah population management is tracking the whereabouts of wild cheetahs. Conservationists need data on their numbers and location so they can step in to help if a problem arises that would affect cheetah health and wellbeing. But cheetahs don’t like to be monitored. Radio collaring, for example, causes them stress. The age-old way of reading their tracks appears promising as a non-invasive method. The article proclaims: “San Bushmen can consistently identify individual cheetahs from their footprints.”

So, the tourist industry and conservationists want to track cheetahs and San Bushmen know how to track them. Does this sound like a wonderful opportunity for the San to benefit from tourism by using their traditional tracking knowledge?

No such luck. The article further states that AfriCat is partnering with WildTrack, an animal monitoring group that aims to use computers to produce an algorithim to track free-roaming cheetahs based on data about their footprints. Computers will digest San knowledge and generate output for scientifically technicians to use.

Here is a shining example of how indigenous knowledge has potential to contribute to conservation and cultural survival by providing employment to the San people who have been harshly displaced from their homelands. Instead, once again, a takeover — only this time of knowledge instead of land. The takeover is glaringly obvious in the article’s proclamation: “Bushmen put scientists on the right track” followed by the words of a European cheetah researcher at a wildlife sanctuary in Namibia: “We hope computers can do the same.”

Photo, “Cheetah”, from Flickr via Creative Commons.

Anthro-pologies to both sides

Guest Post by Nick Bluhm

Students of anthropology face a renewed debate about the role of anthropology in the military, one that has recently drawn the attention of the Executive Board of the American Anthropological Association (PDF) and the ire of many professional anthropologists. The American military, intent on surmounting the Taliban in Afghanistan, has sought out the expertise of social scientists, including anthropologists, as a means to enhance their counterinsurgency tactics.

Two contrasting views shape the debate. Critics deride anthropology for its role as what they scathingly characterize as “the handmaiden of the empires.” These commentators see anthropological involvement in U.S. military operations as a return to the 19th century when anthropologists assisted governments in maintaining control over colonized people. In contrast, anthropologists who have joined the Pentagon’s Human Terrain System to aid in the Afghanistan war effort depict critics as malcontents who subscribe to an antiquated view of anthropology as a purely academic pursuit. Engagement, they conclude, is better than opposition and non-engagement.

Between these extremes, I see the potential for some fruitful middle ground. Most importantly, anthropologists could influence the manner in which the war is conducted, with possible effects on the length and consequences of the military occupation. Indeed, the need for an anthropological perspective in U.S. military strategy is ever more pronounced today. As General McChrystal stated emphatically in his August 30, 2009 Afghanistan report, “…focusing on force or resource requirements misses the point entirely…our objective must be the population.” Furthermore, “gaining [the population’s] support will require a better understanding of the people’s choices and needs.” Anthropologists who focus on researching local culture could enhance the effectiveness of the governance and development aspects of the counterinsurgency.

However, before anthropologists will be seen as contributors to foreign policy discussions, they must indicate that they are willing to work with the U.S. government, though in ways that accord with the discipline’s ethical principles.

While I acknowledge the value that anthropology could contribute to international relations through more socially informed military activities, I also see specific problems with anthropologists assisting the U.S. effort in Afghanistan. I believe that the current U.S. strategy in Afghanistan is founded in part on faulty assumptions, largely reflecting the desires and values of foreign diplomats and not those of the local people. Furthermore, while fighting terrorism is an altruistic goal that affects global stakeholders, the strategy largely disregards the anthropological focus on the needs of the local population.

And, overall, the results so far are not comforting. Using brute force to achieve peace and security appears to be backfiring. In particular, the U.S. military is finding it difficult to distinguish between the Taliban extremists, and the vindictive locals who attribute the deaths of family members to U.S. forces. By associating with this military operation, anthropologists endanger their reputation as trustworthy researchers.

Obviously, I do not mean to proffer anthropology as a handmaiden of the U.S. military. But the U.S. military will be in Afghanistan regardless of anthropological criticism. Presuming that anthropologists have some control over their assignments, an anthropological presence in Afghanistan could be used to positively direct the means, and possibly the presumed ends, of the counterinsurgency. Further, I see this cooperation as one step in a larger effort to make anthropology relevant to foreign policy stakeholders while retaining the discipline’s concern for marginalized populations.

Nick Bluhm is a public policy analyst at the law firm Cooley Godward Kronish, in downtown D.C. He holds an M.A. in anthropology from the George Washington University.

Photo, “afghanistan,” from Flickr via Creative Commons.

Anthro in the news 9/21/09

· An episode of NOW on PBS discusses a Partners in Health project and includes an interview with Paul Farmer.

· On C-SPAN’s feature, “Top Non-Fiction Authors and Books,” Professor David Vine talks about the U.S. military base on the island of Diego Garcia in the Indian Ocean and the 2000 residents of the island who were forcibly exiled from there by the Americans and the British in the late 1960s and early 1970s. See the earlier post on this blog about Vine’s book, Island of Shame.

· The Hawaii News reported archaeological discoveries on Mokumanamana, a remote and currently uninhabited island north of the main Hawaiian islands. Kekuewa Kikilio, a University of Hawaii anthropology doctoral student, and Anan Raymond, a U.S. Fish and Wildlife Service archaeologist, found a partially finished stone carving, remains of a workshop, and agricultural terraces. Further research is required to provide information on when humans lived on the island and for how long.

· The Bill Moyers Journal featured an interview with Dr. Jim Young Kim assessing President Obama’s health care speech and ideas for reform. Dr. Kim is president of Dartmouth College and, with Paul Farmer, co-founder of Partners in Health. He has an MD degree and a PhD in anthropology, both from Harvard University. In the interview, Dr. Kim links U.S. health care reform to his experiences in global health work: “One of the things that we’ve learned is that community health workers, which are really members of the community who help people go through very difficult treatment regimens, this can work anywhere. We’ve done it first in Haiti. Then we did it in Peru. And then in Africa. But most remarkably, we’ve also implemented that program in Boston, and are now thinking of implementing it on the Navajo reservation in New Mexico…Having someone who just visits every day, just to make sure that you’re taking your medicines and you’re doing okay, that has a huge payoff down the line in terms of overall health outcomes.”