This week in the magazine, Katherine Boo writes about young, poor mothers in the swamps of Louisiana, their children, and a nurse who is trying to change their lives. Here, with Matt Dellinger, she discusses the piece.
MATT DELLINGER: This week you write about the Nurse-Family Partnership, a program in which nurses intervene in the lives of poor, first-time mothers-to-be and try to help them create a more stable environment for their children. What drew you to this story?
KATHERINE BOO: I’ve spent a fair amount of time over the years with young children in both poor and affluent communities, and what I’ve seen agrees with what a growing body of social research suggests: by the time most low-income children start elementary school, they’re already so far behind their more privileged counterparts that the educational gap is almost unbridgeable. In America’s moneyed and well-educated quarters, parents spend easily a thousand dollars a year on Baby Einstein DVDs, smart-baby sign-language classes, and other efforts to give their toddlers an intellectual edge before formal schooling begins, and those things are only a fraction of the total capital, financial and social, that they’re investing in their children. I was drawn to the Nurse-Family Partnership because it’s an attempt to help mothers develop their babies’ minds in situations in which a thousand dollars might be twenty-five per cent of the annual household income, the mothers are often children themselves, and the intergenerational conflict is of a level and an intensity that would have made Erskine Caldwell flinch. It’s a wildly optimistic endeavor. But for anyone who has spent time with very young children and sensed how much of their environments they’re taking in, for better or for worse, the program has a logical appeal as well as an idealistic one.
Where did the Nurse-Family Partnership originate?
A developmental psychologist named David Olds began tinkering with the ideas that became the Nurse-Family Partnership almost thirty years ago, while working in the economically depressed community of Elmira, New York. Olds is the father of three sons, two of them adopted, and his experience as both a parent and a teacher in an inner-city day-care center led him to believe that improving the lives of disadvantaged children should start early—ideally, before those children are even born. In 1977, he got a grant from the federal government, trained some nurses in prenatal care and infant development, and started sending them into low-income homes, where they tried to help pregnant mothers stop smoking and drinking, eat their vegetables, and learn something about the needs and the potential of the lives they were about to bring into the world. After the babies were born, the nurses tutored the mothers on everything from burping techniques to paging patiently through “Goodnight, Moon,” until the babies turned two. The main reason the program has now expanded to sites in twenty states, involving twenty thousand babies annually, is that when Olds set up the model program he also set up a control group, and, over the years, he and his biostatisticians kept following the families who had “graduated” from nurse-visiting to see whether this early intervention had made any difference. The data suggested that it did: the children were less likely to be abused, for one, and their mothers were more likely to be working and in steady relationships with their boyfriends or husbands. And, thirteen years after the nurses went away, the Elmira kids and their moms were still doing better than their control-group peers—a striking finding in social-policy research.
You decided to go to Louisiana, one of the poorest states in the country, to watch the nurses work. Why?
In our conversations, Olds was almost masochistic in questioning the value of his life’s work, so it seemed fitting to me to follow his nurse-visitors in what is, demographically speaking, its least promising setting. Even before Hurricane Katrina, the social indicators were such that the old joke of Louisiana bureaucrats, “Thank God for Mississippi,” no longer applied. And while the nurses there receive their initial training from a nonprofit group that Olds founded for the purpose, the program is run by the Louisiana state government, an institution not historically renowned for its idealism in matters of social policy. As it turned out, though, these bureaucrat-nurses were smart, resourceful, and surprisingly cheerful given the fact that they earned very little and were walking most days into the dark heart of adolescent mama-drama.
Are the Louisiana nurses like their Elmira predecessors?
The Louisiana nurses are a different stripe of social crusader: deeply religious women, in the main, who work their butts off while retaining an awareness of whether their pocketbooks match their skirts and their shoes. Politically, many of these nurses have little in common with the charter nurse-visitors in rural New York—typically Kennedy liberals who were either moved by or directly involved in the civil-rights movement. But, as the nurse-visiting idea has expanded, the nature of the evangels has diversified with the territory. And part of the nurses’ ability to connect with clients, whether in Cut Off, Louisiana, or Bed-Stuy, is that they know the environments, and also the values, that shape the choices of young, poor families. When they push young mothers to finish high school, or to talk to their crying babies instead of slapping them, that familiarity can be part of the leverage.
You follow one particular nurse, Luwana Marts, as she works with Maggie and Alexis, two of the twenty young mothers in her caseload. Talk a little about each of them, and the ways that Luwana wanted to intervene in their lives.
I chose to focus on Luwana’s work with two girls, both high-school dropouts, whose difficulties placed them in the middle range of her caseload. One, a beautiful, skeptical young woman named Alexis Plaisance, had discovered at an early age that the sexual interest of older men could be her off-ramp: a means of escaping a tumultuous family life and finding an approximation of the pleasure and adventure that her childhood had lacked. But when her son, Daigan, was born the adventure seemed to end abruptly, and Luwana’s job was, in part, to help Alexis see her son not just as an obstacle in her pursuit of love and attachment but as an object of that pursuit. The other girl I wrote about is a bright, chronically ill janitor named Maggie Lander, whose mother and father had backgrounds that made her own look privileged. What Luwana was trying to do in this case was to help Maggie and her boyfriend, José, break a cycle of poverty and depression in order to give their daughter, Maia, a less dismal future. But such histories can be tricky to slip.
You write that Luwana had been a poor, pregnant teen-ager in the swamps herself. Does her experience help her help them?
Luwana seldom discusses her past with her clients, not because she’s ashamed of it but because poor teen-age mothers are, understandably, a pretty self-involved lot. And though her own experience is part of what keeps her doing this work, what makes her good at it is that she’s a shrewd student of human nature—including human fallibility, a wide range of which is on display when you’re dealing simultaneously with poverty, adolescence, and an infant. Luwana was a decent basketball player in high school, and sometimes when I watched her work I felt I was seeing the psychological equivalent of pivots and fakes—volatile moments in which her quick-wittedness may even have prevented domestic violence and deterred young fathers from exiting their children’s lives. Which is to say, what makes Luwana effective has a little to do with her having “been there,” but more to do with the fact that she’s subtle and tough.
So is that what makes this program work? The tenacity of its nurses?
Olds’s scheme is inordinately dependent on whether nurses like Luwana stick around long enough to get good at this intense, ambitious work. But it also has two built-in structural advantages. First, the nurturing instruction takes place inside the baby’s home, which promotes far more intimacy and openness than in, say, the linoleum-and-Styrofoam-appointed classroom of a social-service agency. More important, being inside the home gives the nurse, over time, a clearer idea of what a baby’s life in a particular family is really like. She sees the jealous boyfriend raise his hand, the rip in the roof that leaves the crib wet when it rains, or the grandpa, drunk, who leaves his cigarettes burning on the counter. She is in the right place to figure out which battles are most important to fight on behalf of a given child.
The second structural advantage is that the interveners are nurses—professionals who, in poor communities, are free of the social stigma that child-protection investigators or other social workers may possess. In fact, many young Louisiana mothers saw being in the program as status-enhancing—they loved to tell their friends, “I have my own private baby nurse.” This excitement tended to wear off, though, as the mothers realized that the nurses weren’t just coming to help them change diapers but to pressure them to quit smoking or return to high school or make other serious changes to improve the economic and emotional stability of their child.
Is the program voluntary? How do girls get involved?
The nurse-visiting program is officially a voluntary one, although, in Louisiana and other states, judges have been known to “suggest” that troubled young mothers or mothers-to-be enroll in the program or else enter more punitive quarters of the justice system. When, as a matter of psychological reinforcement, Luwana and her fellow-nurses ask their new clients—the literate ones, anyway—to write down what, exactly, they hope to get from the program, the responses are almost uniform. As one young expectant mother put it, “I just want my baby to have a better life thin what I got myself . . . and that they not let anything get in their way of learning and be comeing something, like I dint.” The past tense of that “dint,” by the way, captures something the nurses have to fight against as their work with the mothers begins in earnest: even some sixteen-year-olds consider their lives essentially finished, and the possibility of change remote. Thus the greatest challenge for the nurses is preventing young mothers from bolting the program after they grasp the nurses’ high expectations. And, typically, the young mothers who least want a nurse witnessing their personal and maternal behavior are the ones the nurses know most need help.
In Louisiana, did you see any girls leave the program?
Alexis is one of the sixty-four per cent of young women in Louisiana who abandon the program before completion, and, in the Nurse-Family Partnership database, that particular case will go down as a failure. But, as I followed Luwana, I was amazed that she managed to stay involved with Alexis and her son, Daigan, for as long as she did. Whether or not this involvement will make a long-term difference for Daigan, Luwana’s supervision probably gave his first year more stability and gentleness than it would otherwise have had.
What draws a nurse like Luwana to this job, and why does she stay? How does she avoid burnout?
While some nurses are drawn to this job because there’s reason to believe this sort of work can make a long-term difference, what keeps them in it, I think, is the other nurses. It takes a good deal of imagination, not to mention a sense of humor, to help some of these young families untangle their lives, especially since many of those lives are the product of generations of poverty, abuse, addiction, or depression. There are several extraordinary nurses in Luwana’s unit, and they plainly care about one another’s clients. As Claudette McKay, their supervisor, said, “To do this job right, you have to really like these young women and their families, because, if you don’t, those families will sense it, and you probably won’t work hard enough to give them what they need.” That word, “like,” struck me, because it was unsentimental and unpatronizing and captured something essential about nurse-visiting work. If Luwana had viewed a girl like Maggie Lander as a catalogue of social problems, and failed to take pleasure in Maggie’s independent-minded charm and idiosyncrasies, her expectations would have been pretty low. Instead, Luwana’s real affection for Maggie drove her to ask a very poor and ill young mother for something that was almost impossible: to try to finish high school at the same time that she raised her baby, held down a janitorial job, and coped with an incurable disease. And Maggie’s real affection for Luwana was in large part why the teen-ager began to share that aspiration.
In 2003, you wrote for The New Yorker about another innovative social program, which encouraged marriage as a way out of poverty. Does this focus on the traditional family structure rub anyone the wrong way?
It rubs lots of people, including me, the wrong way when an intense focus on strengthening family structure blinds policymakers to fissures in the social infrastructure that intimate, individual choices can’t change. There’s no doubt that having a stable, two-parent family dramatically improves a child’s long-term prospects. But it’s equally clear to me that many institutions that serve poor children—including those from strong, caring families—leave their potential undeveloped or undermined. And so a crucial part of a nurse-visitor’s job is teaching parents how to negotiate their lives amid structural inequality. Consider Maggie’s daughter, Maia, who was born poor and sick to a teen-age mom with no private medical insurance, in a community where there are only a few specialists available to serve an abundance of destitute, chronically ill kids. That’s a social imbalance that shortens, and sometimes ends, lives, and while Luwana can do little about it systematically, she can and does teach girls like Maggie to fight, in that context, for their children. Maggie looks and sounds even younger than she is, but these days, when she walks into a hospital and demands to see Maia’s medical records, she’ll get them.
Particularly in today’s political climate, how do governments justify continuing to allocate money for social-services programs whose benefits are sometimes hard to quantify, or even prove?American social policy survives on over-promise, and necessarily so, I suppose, given a public that has a limited attention span on matters of poverty and inequality, an unwillingness to be separated from their tax dollars, and general skepticism about government competence in matters from hurricane relief to child-protection services to homeland security. So the politicians and the foundation and nonprofit-organization leaders who care about these so-called social-justice issues have historically made claims about the effectiveness of their pet programs which don’t begin to hold up under scrutiny. This expectation inflation is often perpetuated by journalists who spend a few days in a computer class for welfare moms or a charter school for inner-city kids, then write up the most uplifting stories. Alas, the fact is that many anti-poverty approaches—ideas that seem logical or feel right in situ—turn out, when studied longitudinally against control groups, to make little or no long-term difference in the lives of their alleged beneficiaries. What’s interesting about Olds is that he’s spent decades not only refining his ideas about nurse-visiting but doing what in a weaker program would amount to self-sabotage: raising (with some difficulty) millions of dollars to test whether his idea for addressing poverty will work across demographic, geographic, and generational boundaries. Around the country today, thousands of smart, committed people are running schools and social programs that are clearly benefitting their respective communities, just as the first nurse-visitors did in Elmira, New York. A pressing question is whether such good programs can be replicated—whether they can grow to serve a sufficiently large, diverse population to bring about even a small amount of national change. But people who try to answer that question with real data may find that their diligence redounds to political detriment. Findings like the ones that Olds has produced over the years are complex and replete with caveats: matters of statistical insignificance, data sparseness, and the like. Such nuances can really muck up a PowerPoint presentation, and they don’t lend themselves easily to political crusades. The trouble is that if we don’t evaluate social programs strenuously—and if we’re unwilling to risk the fact that even well-crafted and well-intentioned ideas may do little—we won’t progress very far in crafting the ideas that may do more.