A Valentine To Boo and Banchero: Great Writing About Schools and Home Visits

It's not exactly typical Valentine's Day reading, but I've finally gotten started into what seems like another great Katherine Boo article in the New Yorker from last week, called "Swamp Nurse" about the Nurse-Family Partnership program, an aggressive $4k per case per year early intervention program for poor young mothers in which home visit nurses try to get to issues long before the children get to school.

And that's not all. At the same time, the Chicago Tribune's Stephanie Banchero has put out another of her great features --about a program called System of Care that's taking a similarly aggressive and comprehensive -- intrusive? -- approach. Whether you like the approach or not, or think it works or not, this is top-notch writing about complicated social policy issues.

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I'm halways through Swamp Nurse, and it' s not online (I plan to scan it) (read it below), but I can already tell how good it is. (A Macarthur "genius" grant awardee before she was 40, Boo also wrote The Marriage Cure and The Factory about Pacific Rim charter school in Boston, and this, and this, and this.). Amazing, closely observed, not obviously ideological stuff. There is an online Q&A with Boo about how she made the article and what she learned: Children of the Bayou.

So far, at least, Swamp Nurse is reminding me of another recent piece -- Stephanie Banchero's Tribune Magazine piece about a comprehensive services program in Chicago, which you should also check out. You may recall, Banchero wrote a great series in 2004 about one child's effort to take advantage of the NCLB transfer provision that still stands out in my mind.

All hail, Kate and Stephanie -- mixing detailed reporting with insightful policy analysis.

UPDATE: Here's the article:

February 6, 2006
SECTION: FACT; A Reporter At Large; Pg. 54

LENGTH: 9381 words

HEADLINE: SWAMP NURSE;
What's the best hope for the first child of a poor mother?

BYLINE: KATHERINE BOO

BODY:
In the swamps of Louisiana, late autumn marks the end of the hurricane and the sugarcane seasons-a time for removing plywood from windows and burning residues of harvest in the fields. Then begins the season of crayfish and, nine months having passed since the revelry of Mardi Gras, a season of newborn Cajuns. Among the yield of infants in the autumn of 2004 was a boy named Daigan James Plaisance Theriot, and, on the morning of Daigan's thirtieth day of life, he was seated next to a bag of raw chickens in the back of an Oldsmobile Cutlass. His mother, a teen-ager named Alexis, was in front, squeezed between her younger sister and her sister's latest beau, a heavily tattooed man who had just been released from maximum-security prison. The car came down a road that begins with a bayou and ends in dented trailers, and stopped at a small wooden house.

When Alexis's sister leaned into the back seat to fetch the poultry, the young man, grinning, slipped a hand down the back of her jeans. Alexis stared at the couple for a moment, then pushed them aside to pick up Daigan. Alexis's hair was long and streaked with pink, and her face was a knot of frustration. As Daigan began to cry, she crossed the yard denouncing in absentia his father, whom she called Big Head: "If I see him, I will hurt him-Big Head asking for it now." When she reached the porch, which was crammed with auto parts and porcelain toilets, she fell silent, then forced a smile. Amid the fixtures stood a tall black nurse.

The nurse, Luwana Marts, holds one of the stranger jobs in the Louisiana state bureaucracy: she is a professional nurturer in a program called the Nurse-Family Partnership, which attempts to improve the prospects of destitute babies. A few months earlier, Alexis, eighteen and pregnant, had arrived at a local government office seeking Medicaid for her impending delivery. She ended up with both the Medicaid and Luwana. As a rule, Cajun families don't welcome government intervention, especially when it occurs inside their homes, involves their infants, and means the presence of a dark-skinned person. To some parents, Alexis among them, Luwana was a spy in the house of maternity, and so she now and again had to lie in wait for reluctant beneficiaries.

Alexis maneuvered herself and Daigan past the toilets, from which cacti had started to grow, and pushed open the front door with her hip. She entered a combined living room, dining room, kitchen, laundry, and storage facility that was home to five people, a dying cockatoo named Tweety, and multitudes of flat silver bugs. Luwana followed Alexis, Daigan, little sister, and boyfriend inside. That morning, feeling the onset of flu symptoms, Luwana had decided to avoid contact with the infants she called her "little darlings." In the field, though, calculations of risk were subject to change. She dropped her satchel, slathered her hands with Purell disinfectant, and reached out. Alexis handed over Daigan and wrapped her arms tightly around herself. "So, tell me," the nurse began with practiced tranquillity as she scanned a body in a playsuit for damage. "Not the happiest day of your life?"

Alexis and nineteen other girls in Luwana's caseload call her their "nurse-visitor," a term whose genteel ring seldom comports with the details of her job. She is one of eight nurses, all mothers themselves, who work the parishes of Terrebonne and Lafourche, persuading poor first-time mothers-to-be to accept assistance. The Nurse-Family Partnership model is currently being tried in Louisiana and nineteen other states on the basis of promising preliminary results-results achieved in the face of the nurses' preposterously difficult assignment. In regular visits until a baby is two years old, they try to address, simultaneously, the continual crises of poverty and the class-transcending anxiety of new maternity: this creature is inexplicable to me. Despite its ambition, the program is rooted in a pessimistic view of the future that awaits an American child born poor-a sense that the schools, day-care centers, and other institutions available to him may do little to nurture his talents. Shrewder, then, to insulate him by an exercise of uncommon intrusion: building for him, inside his home, a better parent.

Thus, no matter how chaotic the scene-no matter that Alexis's sister had taken a break from hacking chicken parts by the kitchen sink in order to satisfy the ex-inmate's sexual needs in the next room-Luwana's first task is to create an aura of momentousness around the new baby. As she moves through a household, giving advice about routinebuilding, breast-feeding, and storing shotguns out of reach, she attempts to win over not just a young mother but a typically unwieldy cast of supporting players, from the baby's father to the greatgrandmother getting high in a tent behind the house. What Luwana tells each family may seem, on the face of it, fiction: that in this infant enormous possibilities inhere. But such fictions can be strategic, especially in cultures in which the act of becoming a mother is honored far more than what the mother subsequently does for her child.

Alexis, who wore a tight red T-shirt, would have been striking even without the pink improvements she'd made to her caramel-colored hair, and since fifth grade, when she'd lost interest in schoolwork, most of her opportunities had come from men who'd taken note of her looks. Lately, she'd been wishing that she'd had a longer, simpler childhood, but, in the childhood that she had, full hips and breasts and lips had served her well. They served her less well now. To Luwana's questions about Daigan's feeding schedule, she responded monosyllabically while studying her manicured fingers. She'd received the manicure, plus some blue balloons and a chocolate-chip cake, on what she called the "heartful" occasion of Daigan's birth. The days preceding his arrival had not been happy. Alexis lived with her mother and father, a grocery clerk and a construction worker who were in constant conflict. When Alexis was eight months pregnant, the fights grew so fierce that she fled the household altogether. Her recent return testified less to domestic reconciliation than to the impact that a squalling baby has on the sleepover invitations a girl receives.

As Luwana tried to draw Alexis out, the phone rang, and Alexis covered her ears. "I'm guessing this is Daigan's dad who keeps on calling," Luwana said, after the third round of unanswered rings. Alexis met her eyes for an instant, then burst into tears. "O.K., now," the nurse said, "spell it out for Miss Luwana." Between sniffles, the proximate cause of distress became clear. Daigan's father, a sturdy twenty-six-year-old named James, worked on a tugboat on the Mississippi River. That weekend, he would be returning to shore and expected to have sex with Alexis, though she was not healed from childbirth, nor was she using contraception.

"No way!" Luwana said. "Keep your legs closed: embed that in your brain. Tell him to keep his hands to himself. And if you can't stand up for yourself, stand up for Daigan. You've got a lot of work ahead, giving him what he needs. Look around, Alexis. You need another baby in this picture?"

"No," Alexis said dully. Then she brightened: "Miss Luwana, maybe you can write me an excuse note, like for gym?"

Luwana's church friends smiled knowingly when they learned that she worked for the state. They pictured cubicles, potted plants, and cushy hours. She seldom corrected this impression, nor did she say that some mornings, driving her six-year-old Maxima toward some difficult case, she wanted to turn north and spend the rest of her working life in more high-minded quarters. But Luwana's efforts were invigorated by the fact that twenty years ago she was herself a poor, pregnant teen-ager in these swamps. "I know now that there were government programs on the books designed to help girls in my situation, but back then, especially if you were black, you didn't hear about them," she said. She is now thirty-eight, with two sons and a husband who has spent most of his working life in a mill that makes paper cups. It took her fourteen years, between child-rearing and stints as a nurse's aide, to earn a bachelor's degree in nursing. Her state job pays thirty-five thousand dollars a year, half of what she'd make in the emergency room of a private hospital. "Oh, I have my material longings-every so often I'll throw a pity party for the house I'll never have," she said. "But quite a few of us nurses are working, you could say, in the context of our own memories."

"How he doing?" Alexis asked uneasily, as Luwana's fingers explored Daigan's soft spot.

"You're the mama," Luwana responded. "You tell me."

"He's got a big head like his father," Alexis said under her breath. Then she rallied: "He's not as cranky as he was. And one thing I learned already is how he cries different when he's hungry than when he's wet." Luwana bestowed on Alexis a dazzling smile that she had thus far reserved for Daigan. "Making that distinction is important," she said. "You're listening to him, and in his own way he's explaining what he needs. Pretty soon now he'll be making other sounds, and when he does you'll want to make that noise right back. He'll babble, and then you'll talk to him, and that's how you'll develop his language. Now, what you may also find, around five to eight weeks, is that he'll be crying even more-it's a normal part of his development, but it can also stress out the mom, so we'll want to be prepared for it. The main thing will be keeping calm. And if you just can't keep calm-if you find yourself getting all worked up and frustrated-well, then what?"

"Put him down? So I don't hurt him, shake him, make him brain-dead?"

"Put him down and . . . ?" Luwana drilled her girls hard on this particular point.

"Call someone who isn't upset? Let the baby be, and get help."

Luwana turned to Daigan and clapped. "See, your mama is getting it," she said, using the high-frequency tones that babies hear best. "She's surely going to figure you out."

There was a trick that Luwana relied on to stave off dejection: imagining how a given scene would unfold if she weren't in it. In Alexis's case-one that, in terms of degree of difficulty, fell roughly in the middle of her caseload-she knew that slight improvements had already been made. At Luwana's urging, Alexis had stopped drinking and smoking when she was pregnant and had kept her prenatal appointments. So she wasn't incapable of changing her life on Daigan's behalf; the odds were just long.

Sitting cross-legged on the floor now, Luwana sang "Clementine" and made faces at Daigan, and for a moment Alexis studied this demonstration of engagement with her child. But then her gaze drifted over to her sister and the ex-con, who had emerged from the bedroom to chop the rest of the chicken. The young man, whose tattoos included whitesupremacist ones, put on mirrored sunglasses for this task, a fashion choice that made Alexis giggle. Luwana's primary subject that day was infant attachment, a topic she tailored to fit Alexis's limited attention span. "A funny thing about the axe murderers," she said casually. "Usually something missing in the love link." And, indeed, axe-murdering seemed to register with both Alexis and the former prisoner, who set down his knife and came over. "I need to hear, too-mines is horrible," he said. "We whup him but since he turned two he don't do nothing we say, probably 'cause his mama on drugs and sleeping around and getting locked up-well, she's a whore."

"You hit a two-year-old?" Luwana asked, her eyes narrowing. "You teach him how to fight and are surprised when he turns around, starts fighting you?" She then fixed her stare on Alexis, who began examining the brown linoleum floor.

"The love link," Luwana began again. Now the room was still. "It's a cycle. When there's no safe base for the baby-when you're not meeting his basic needs, satisfying his hunger, keeping him out of harm's way-there will be no trust, no foundation for love. And that's when you might just get the axe murderer. Maybe sometimes we have a baby and expect that baby to comfort us? Well, sorry, it works the other way around. It's on you now to comfort him, earn his trust, because that's how Daigan is going to learn how to love."

Infant-development strategies, like other forms of social capital, are perversely distributed in America-fetishized in places where babies are fundamentally secure and likely to prosper, undervalued in places where babies are not. The nurse-visiting program aims, in a fashion, at equalization. The territory that Luwana and her colleagues cover begins an hour's drive southwest of New Orleans, down fog-prone highways lined with cypress trees which lead to the Gulf of Mexico. On the shoulders, turkey vultures pause, flicking mud from their wings. Mississippi River sediment shaped this marshy delta, to which eighteenth-century French Acadians, expelled by the British from Nova Scotia, laid a claim not hotly contested. The terrain now occupied by the exiles' descendants is muggy, heavily wooded, and visited so often by hurricanes that Katrina, which made landfall near here, failed to register as a main event. Residents have another, steadier battle with nature, because they've built their lives on one of the fastest-sinking landmasses on earth.

The social demographics are almost as fragile. Louisiana literacy rates are among the nation's lowest; infantmortality and child-poverty rates-thirty per cent of all children are poor-are among the very highest; and almost half of all births are to single mothers. Historically, the swamp region's topography isolated it from the rest of the state, but drawbridges and thoroughfares have been erected in recent years, and cane fields now give way to Wal-Marts. Still, idiosyncratic child-rearing beliefs endure: a baby will become constipated if held by a menstruating woman; formula is healthier than breast milk; giving an infant a haircut before his first birthday will stunt his growth and hurt his brain.

The cases that Luwana and her fellow-nurses take typically begin with a referral from a public-health or prenatal clinic: a form indicating the age and address of an expectant mother and the baby's due date. Occasionally, a nurse shows up at the given address to find a mother-to-be converting Sudafed to methamphetamine on a hot plate. Other times, a pregnant girl's father is hostile because he's the probable father of his daughter's child. But the nurse's typical commission is to work with what she finds. And while Luwana believes that some aspects of mothering are instinctual, what she teaches is more like applied science. Her tools include a polystyrene demonstration baby named Dionne, picture books, a raft of developmental checklists, and, above all, her trade's bleak knowledge: babies can get used to almost anything-as many of those babies' mothers had.

The Nurse-Family Partnership program began twenty-eight years ago as the obsession of a developmental psychologist named David Olds. He is fifty-seven years old, with clear blue eyes and a tendency to fidget not unlike that of Luwana's adolescent mothers. He grew up in a working-class household and as a young man taught in an inner-city day-care center, an experience that led him to suspect that by age four or five some children are already gravely damaged. In the nineteenseventies, after earning a Ph.D. at Cornell under the late child psychologist Urie Bronfenbrenner, he began working with colleagues to translate this grim view into an elaborate scheme of prevention. At the time, scientific knowledge about early brain development and the importance of a child's first years of learning was more limited than it is now. But for Olds, who has one biological child and two adopted children, intuition as much as evidence suggested that the rescue effort should begin before birth, and unfold in the setting where an infant would spend most of his time. As for what sort of person a low-income young woman might trust inside her home, he and his colleagues settled on nurses, who in poor communities have high status and medical expertise that many pregnant women want. In 1978, Olds used a federal grant to test his idea in Elmira, an economically depressed, mostly white community in New York's Southern Tier, which had the highest rates of child abuse and neglect in the state.

"Some policymakers look for cure-alls, which this isn't," said Olds, who continues to study his protocol's effects as the director of the Prevention Research Center for Family and Child Health, at the University of Colorado, in Denver. "We keep refining how we do this as the nurses report back on their experiences, because there's still a lot that we don't know-for instance, how best to help mothers who are battered or mentally ill." Nonetheless, when he conducted random-assignment evaluations (among the most strenuous tests of a social program's effect) to gauge how the Elmira mothers and children were faring at the completion of the program, he found more improvement than he had expected. One of his chief concerns had been child abuse, and it turned out that children whose mothers had finished the nurse-visiting program were far less likely to be abused or injured than their counterparts in a control group. He also discovered that by the time the nurse-visited children were four, their mothers were more likely to be employed, off public assistance, and in stable relationships with their partners. Evaluations of two subsequent pilot programs-with primarily black families in Memphis and a racially diverse group in Denver-showed less dramatic results against control groups but suggested additional possibilities. By age six, for instance, the nurse-visited Memphis children had larger vocabularies, fewer mental-health problems, and slightly higher I.Q.s. In all three sites, the mothers had fewer subsequent children and longer spaces between them. An economic analysis of the Olds experiment commissioned by the state of Washington concluded that the approach-which currently costs around four thousand dollars per year per family-was cost-effective as well, because the children aided by the nurses had required fewer expensive social services such as foster care and hospitalization.

The early optimism surrounding programs meant to help poor children is often dispelled by the rigorous assessments that come later. Children may make startling intellectual and functional gains in the hothouse of a model program-say, a preschool run by skilled and idealistic teachers-but those gains tend to vanish when the children move on to their communities' less hospitable institutions. This phenomenon, known as "fade-out," is one of the great frustrations of antipoverty policy, and I was first drawn to Olds's work because his long-term findings seemed to defy the regressive trend. By the time the Elmira children turned fifteen, they were still demonstrably better off than their controlgroup peers. For instance, they'd been arrested far fewer times, one of several findings that inspired the U.S. Department of Justice to cite Olds's infantintervention program as a model for the prevention of juvenile crime. I wondered, however, about the objectivity of the Olds studies, since, regardless of acceptance by peer-reviewed publications like the Journal of the American Medical Association, he is essentially grading his own work. When I raised specific questions about the long-term outcomes in Elmira, Olds decided to recalculate his data using seven different evaluation methodologies, grasping that such a test might undercut his life's work. He later reported that some of the original findings-for instance, those about Elmira teen-agers drinking and running away less than their counterparts-weren't holding up under a preliminary analysis. He was so dismayed by these results that he seemed oblivious of the fact that other evidence of the improved futures of nurse-visited children and their mothers was now about as solid as findings can be when the subject is social policy's impact on human behavior.

The nurse-visitor approach makes some liberals uneasy, because they fear that its focus on good parenting will undermine the fight for decent schools, quality day care, and other institutional supports for poor children. Libertarians recoil at a government-funded program that meddles in private lives, and child-welfare advocates have been frustrated by Olds's restraint. In their view, a "scientifically proven" approach like nursevisiting could have attracted bipartisan support and been widely implemented years ago, if its creator had more emphatically promoted it.

Olds's cautiousness is based not just on a sense of personal fallibility but on what he considers the faltering of Head Start in the late sixties and seventies. A rapid, politically driven expansion inflated public expectation while diluting program standards; by the eighties, conservative policymakers were using Head Start's modest results to justify the rejection of other government antipoverty programs. Olds wants his protocol to expand incrementally, as he fine-tunes it. Currently, thanks to a hodgepodge of public and private funders, nursevisitors in places as diverse as Los Angeles, Fargo, Allentown, Tulsa, and BedfordStuyvesant serve an annual twenty thousand of the United States' 2.5 million low-income children under the age of two.

Louisiana, where I decided to watch Olds's ideas at work over the course of a year, is one of nurse-visiting's most difficult settings. Legislators there have been sufficiently impressed with the program to more than double its size in four years, with the help of federal Medicaid dollars. But, in a state where nurses often run out of breath when recounting the disadvantages of their clients ("The mom I'm working with now is a sixteen-year-old unmedicated, bipolar rape victim and crack-addicted prostitute with a pattern of threatening to kill her social worker, who recently abandoned her baby at her ex-boyfriend's sister's, and who has an attempted murder charge in another situation-well, I think I've got all the risk factors," a colleague of Luwana's said one day), nurse-visiting is unlikely to be mistaken for a cure-all.

In the bayou, every schoolchild knows that a shrimp's heart is in its head, and that now it's cheaper to buy that shrimp from China. So last winter, in a neighborhood called Upper Little Caillou, people who once worked on the water were trawling for a servicesector niche. On homemade signs in yards, the inventory of salable goods continually evolved: "Shrimp/Alterations/Vinyl Blinds"; "Turtle Meat, Adult Novelties & Bail Bonds." Maggie Lander, a seventeen-year-old client of Luwana's, was among the residents hawking what she imagined rich people might want, such as her mother's cache of Harlequin novels. In the interest of clarity of message, though, the front of her home bore just one sign-"No smoking"-on behalf of her one-year-old daughter.

In a few years, Maggie figured, her daughter would perceive the deficiencies of her home, as Maggie did-understanding, for instance, that a sheet stapled to the ceiling wasn't what people usually meant by an interior wall. But she chose to believe what Luwana had told her: that babies didn't care about the surface of things. Their standards were deeper, Maggie believed, than those of some grownups she knew.

In addition to selling secondhand goods, Maggie worked for a janitorial service. She has a lisp, a vulpine face, and auburn hair that she parts down the middle and often lets fall over her eyes. When Luwana came around, though, Maggie tucked the strands behind her ears, revealing the sallow beauty of a Victorian consumptive. For a half-Mexican, halfNative American schoolmate named Jose Hernandez, the sexual attraction had been intense. It wasn't entirely an accident when, after a year and a half of courtship, she got pregnant.

In the bayou region, which is traditionally Catholic, no doctors admit to performing abortions. Home remedies, though, are highly evolved: blue cohosh root, a belly flop from bed to floor, the placenta-rupturing magic of cocaine. ("Is the baby shaking yet?" practitioners of this late-stage strategy asked when they entered the local emergency room; they knew the drill better than the doctors did.) But most pregnancies here were not terminated; as Maggie's mother liked to say, "God doesn't make mistakes." Maggie concurred with this theory. Still, when Luwana first appeared on her broken front porch, she was relieved to have a fresh pair of eyes on her life.

David Olds and his researchers like findings that can be quantified, and Luwana has learned to report her experiences accordingly. The forms she filled out, however, didn't always capture the extent of a family's despair. The first time she'd come to Maggie's house, she had found an intelligent, underfed tenth grader in her second trimester who was sick with untreated hepatitis B and was also trying to care for her mother, who was bedridden and weighed eighty-two pounds. "I was in another world then, wanting to die," Maggie's mother, whose name is Tammy, recalled. "I'd been played the fool by a man I thought wanted a wife." Though mother and daughter shared malnourishment, depression, and very close quarters, they seemed to exist in separate spheres.

One afternoon before Christmas, the effects of Luwana's yearlong campaign against hopelessness were easy to see. The baby, whose name is Maia, was an exuberant babbler, with a paunch so magisterial that her patchwork jeans were left unbuttoned. Maggie's mother was rounder, too, thanks to antidepressants, and she was working alongside Maggie at the cleaning company. Maggie was buoyed by her recent engagement to Jose, whom Maia plainly adored. He had moved into the house shortly before his daughter's birth, and he, Maggie, and Maia now occupied a sweltering room in the rafters.

As Maggie discussed her low-budget wedding plans with Luwana, she bounced her dark-skinned daughter gently, while her fingers traced shapes on the baby's thigh. Maggie had become a diligent student of child-development technique, reading aloud so often from the parenting handouts Luwana had given her that she got on Jose's nerves. "She's, 'Listen to this on early brain development,' and I'm like 'O.K., I was here when Luwana went over it, I know,' " he said. "But she has to memorize this stuff." Luwana, of course, found the habit agreeable, and privately gave Maggie her highest praise: "The girl's an overcomer." But, in the swamps, a massively improved life is not the same as a good one.

Maggie was now weak from the interferon that Luwana pressed her to take for her hepatitis. Maggie didn't know whether she had caught the disease from the twenty-five-year-old to whom she lost her virginity, at age thirteen, or whether she had been born with it. But the combined pressures of infirmity and maternity had led her to a decision with which Luwana took strong issue: dropping out of school after Maia was born.

"I'm just trying to see that we're taking logical steps here," the nurse said gently. A fiercer iteration of her argument-that bearing a child as an unmarried teen-ager and failing to finish high school were matchless predictors of lifetime poverty-had just brought tears to Maggie's eyes. "You have too much to lose, and I know you don't want to clean houses all your life. Remember when I met you? It was one of the first things you said-how adamant you were about finishing?"

"I will go back, Miss Luwana, I promise," Maggie replied. "It's just now, with my job and Maia doing so many new things-I don't know. . . ." Luwana's concern with diplomas, career plans, and jobs with benefits wasn't shared by many people Maggie knew. In a sinking region, land and housing came cheap, and dinner could be yanked from the brown water, so uneducated people could in fact "work the odd one," "do for themselves," and get by.

Luwana, like many of her clients, is good at suppressing emotion. Among her cases were a young mother who had attempted suicide in her third trimester, two others who'd been violently abused, and one who was paraplegic and mentally disabled. Maggie's case troubled the nurse differently. She saw in the girl something of her younger self-"You know, that caged bird singing"-and feared the potential was going to be lost.

"I mean, I'm not going to be just some dropout," Maggie promised Luwana now, gathering conviction. She reminded the nurse of a pact she'd made with Jose, who worked nights with her on the cleaning crew and spent his days in high school. He'd get his diploma while she took care of Maia, then it would be her turn for school.

"So he's going to be the main one keeping Maia, is that what you're saying?" Luwana said skeptically. "You're going to trust him with her next year when you don't trust him now-when he doesn't wake up when she's crying?" In the year that Luwana and Maggie had spent together, Luwana had grown alert to the girl's romantic habits of mind.

When Maggie and Jose cleaned houses for lawyers and car dealers, Jose enjoyed discoveries of drug stashes and signs of affairs. "Wife large," he'd say with a broken-toothed smile, brandishing a find. "Panties behind the trash can in the bathroom, petite." Maggie preferred to dwell on other evidence. "I like dirty kitchens more than the fancy spotless ones," she said, "because in the dirty ones you can picture the homey wife and the father and kids all eating together and talking like a family." She hoped to replicate this scenario with Jose and Maia.

"Let's see," she said one day of the family life she had personally experienced. "In the last few years, we stayed in that trailer park we couldn't afford, then the little blue house we couldn't afford, either-had to give it back. Then a trailer park, then my auntie's trailer when we couldn't afford the trailer, then back to the trailer park, then straight to a little bitty camper behind my aunt's trailer-now, that was tiny, you walk in the door, there's a mattress and a table and that's it. Then we moved in with my uncle, then with my mom's boyfriend, then back to the trailer park, then back to the boyfriend, then back to my uncle, and then here."

Luwana had bettered her own circumstances with the help of caring teachers and strong parents, neither of which Maggie seemed to have. Her father, an illiterate as well as an addict, beat her mother when Maggie was young, and then his neck was broken in a car wreck. Afterward, he got sober, found religion, and separated from Tammy. Both parents are devoted to Maggie, but their leverage is minimal. "I hear Luwana saying to Maggie, 'It's not about you, you're making decisions for your daughter now,' " Tammy once said, "and I can almost see it on the tip of Maggie's tongue, 'But you didn't, Mom. You didn't look out for me.' " Tammy thought often about a day, shortly before Maggie got pregnant, when her daughter told her she was suicidal. "I didn't want to hear it," Tammy said. "I just wanted to believe that Maggie was the one thing in my lousy life I'd done right." Now Maggie considered Maia one thing that she was doing right.

Luwana crouched to study the teen-ager as she and Maia played with a set of plastic blocks. Some adolescents were reluctant to play with their babies because it violated their code of nonchalance. Maggie, though, played zealously until Maia lost interest and tried to crawl away. When Maggie picked her up, Luwana objected: "She's at an age where it's good for her to explore. You want to let her learn to be independent."

"House isn't safe," Maggie said, running her hand across a patch of rough plywood. "I gotta keep her in one place."

"Your authority is her safety, too," Luwana said, then whispered excitedly in Maia's ear, "Let's see you walk! You want to walk? I think you want to walk!"

"She doesn't want to, she's not ready," Maggie protested. Luwana raised an eyebrow, and then they both laughed. It was Maggie who wasn't ready. She said, "It's like, stop here where it's happy, because what if the rest ain't this good?"

Every December, Santa Claus comes down the bayou on a shrimp boat twinkling with lights, at which time bitterness begins to rise in a swamp nurse's heart. This is the season when families whose financial and emotional problems she's been working for months to unravel go deep into debt, drink themselves into oblivion, and beat each other up with more than usual frequency. On Christmas Day, their babies get "Lion King" DVDs that they can't watch, because the television has been repossessed. For Luwana, the rest of the winter is mop-up.

One morning in February, Luwana and six other nurses gathered at the Terrebonne Parish Health Unit, in a low-slung concrete building situated between a shabby neighborhood and an oil rig. A space shortage meant that the nurses conducted their weekly meetings in a storage area, but to Luwana the hours there were luxurious-a time of reassurance that she wasn't working alone.

Waiting for the late arrivals, the nurses discussed the deficiencies of the Atkins diet and the doings of their own adolescent children. Luwana's younger son was a smart and willful twelve-year-old, and the other nurses nodded knowingly at her assertion "I'm better with other people's kids than I am with my own."

The meeting came to order with the appearance of Claudette McKay, the unit's fifty-seven-year-old supervisor; she'd been one of the first nursevisitors in the region-apparently a memorable one. At noon the day before, as she drove through Terrebonne Parish to a local diner, a young woman in a skullcap yelled in her open window, "I'm going to carjack you!" "You skipped your birth-control appointment!" Claudette barked back, unfazed, as the girl, a client from four years ago, smiled sheepishly and promised to return to the clinic. A few minutes later, as the nurse ate lunch, a little girl across the diner started gesturing wildly in her direction. "One of mine," Claudette said. "Interesting how, years later, they still react to the voice."

Now Claudette's bifocals slid down her nose as she ripped through orders of business, one item of which was the resignation of a nurse, who had taken a less stressful job. Then she turned to Luwana: "Which of your wonderful cases do you want to tell us about today?" Claudette could be hard on Luwana, whom she'd hired two years before. At the time, Luwana had envisioned a job that left time for her husband, children, and the teen-agers she tutored and counselled at her church. But in a place where resistance to nurse-visiting was great, and sixty-four per cent of mothers abandoned the program before their children turned two, Claudette expected-and in Luwana's case eventually got-passionate commitment.

Although passion is tricky to sustain in the winter, Luwana took solace in two girls she called "my model moms" and in the unexpected stability of Alexis. On Valentine's Day, the teen-ager had accepted a marriage proposal from Daigan's father, who had a steady income from tugboat work. They'd moved into an apartment down the street from her parents, which Alexis planned to decorate in "purples and blues." Away from her parents' home, she seemed happier and marginally more attentive to Daigan; she was also, finally, on birth control. So today Luwana solicited her colleagues' advice on a different case: a household in which, as she worked with the mother and baby, a libidinous grandmother kept trying to feel her up. "I try not to make a big deal about it, because I don't want to lose the trust I've gained with the family," Luwana said. "But I have to say, Eeeeeee! I don't like it."

As the other nurses burst into laughter, Claudette, who happened to know the grandmother in question, suggested that a confrontation wouldn't be as counterproductive as Luwana feared. "Next time she tries, you just say, 'Honey, back it up,' " she advised. "She'll get that sort of language, since she's all in your face herself."

The discussion moved on to several mentally retarded mothers who, inexplicably, had been cut from disability rolls. The nurses sometimes had to scramble to prevent retarded mothers and their children from being evicted while convincing the bureaucracy that the person who had an I.Q. of sixty last year had roughly the same I.Q. now. And then the nurses turned to a case that worried them all: a withdrawn seventh grader in a violent household who appeared, in her third trimester, to be starving her baby.

One of the nurses said, "I'm at that door every day, but they won't open it, and now she's not going to school. I'm afraid she'll try to abort the baby on her own." The nurses hoped to get the girl into a Baton Rouge home for expectant mothers-and quickly, because when last seen she had been bloody from a fight with her mother. This abuse had been reported to child-protection authorities, who concluded that the girl was safe where she was.

That week, state officials were vowing to reform the child-protection system, after a violent shaking left an eight-month-old boy in a nearby town brain-dead. But the nurses understood what was left unsaid: though state child-abuse deaths were rising, a shortage of child-protection workers, family services, and foster parents meant that at-risk children were often stuck in dangerous homes. The nurses eventually decided that the safety of the seventh grader necessitated what they called "the back-channel option," involving an appeal to a sympathetic local judge. Then the women grabbed their satchels and headed out down the bayous, to fresh troubles they would keep to themselves until they met the following week.

"How many centimetres?" Luwana said into her cell phone one day as she drove down the highway. "Well, baby, that's what the epidural is for, you don't feel it. Sometimes it also gives you chills, be ready for that. I'll be there as soon as I can." Luwana's niece was about to give birth after what the nurse called "the longest pregnancy, emotionally speaking, on record," and Luwana had been at the hospital most of the night. Her fatigue was exacerbated by the fact that her next client, Alexis, had just left a message telling her not to come. Luwana turned off the main road and drove down gravel paths in search of a cell-phone signal. First she called Alexis's sister, whom she had recently turned into an informant, and who reported that Alexis and James, her fiance, had been brawling. "Look, Alexis, I'm not trying to get in your business," she was saying a few minutes later, "but Daigan is my business. O.K., O.K., can I see you tomorrow? No, I need to see you tomorrow." When she hung up, she said, "I don't feel good about this."

Although by now Alexis had mastered the good-mother script-"I can't stand leaving Daigan, he's developing so fine and I don't want to miss nothing"-the baby seemed, at six months, to contradict her. He was lethargic and close to obese, which Luwana attributed to Alexis's discovery that overfeeding a baby will make him sleep more. As she fretted, her cell phone rang again. "Eight centimetres?" she said in a voice considerably brighter than her mood. "Baby, I'll be there as soon as I can."

Her last visit of the afternoon was with an introverted young woman named Krystal. (Many teen-age mothers on the bayou are named either Krystle or Alexis, after feuding characters in the television show "Dynasty," which was popular when they were born.) Four months earlier, when Krystal's son was two weeks old, the young mother had seemed overwhelmed by her baby, and further rattled by a belief that, after a Cesarean, the obstetrician had left his instruments in her belly. Since then, Krystal had become improbably adept with her son. "My pa be saying, 'There's something wrong with your baby, all these noises he's making,' " she now told Luwana, laughing. "I told him, Pa, you ain't know about preverbal-my baby is talking." Krystal, like most of the literate mothers in Luwana's caseload, was now reading to her baby as well as talking to him, and had become obsessed with his developmental progress. That day was her son's four-month evaluation, and Krystal watched solemnly as the nurse explained the neurological, auditory, and visual cues she was looking for, and jotted estimations in a notebook. After several minutes, the nurse sat up straight. "Mama!" she announced. "He's on task!" Relief flooded Krystal's face.

By the time Luwana left the house, another impoverished baby had joined the citizenry of Louisiana: her niece's six-pound-ten-ounce son. Outside Terrebonne General Hospital, the new father was waiting to dramatize the day's high points: "Man, I be getting sick with they snipping her little bits to get the baby out. But guess what," he added mischievously, "he got a hairy back just like his mama." In the recovery room, Luwana hugged her niece and dropped a gift bag on the table: condoms and contraceptive foam. "This is wonderful," Luwana told the couple, shaking her head. "And it's going to be a long, long time before you do it again."

Luwana waited again on Alexis's porch. "I knew she would do me like this," she said, rising on tiptoe to check a bedroom window. By now, she was expert in the ruses of the poor: although they couldn't afford to stay away long, they were often quite good at hiding. After a few minutes, she gave up and got back into her car, at which time something down the road caught her attention. She swallowed hard and hit the gas, overtaking a strapping, sunburned man on a motorcycle.

"James!" she yelled, leaning out the window. Daigan's father turned around, surprised.

He climbed off the bike, removed his helmet, and stared past the nurse toward Alexis's little wooden house. "Well," he said, "she broke my heart. And you know all what I did for her-you saw."

Luwana got to the point: "Where's my baby?"

"The new guy got no job, on drugs, on parole, got warrants out for his arrest. And"-James's tone suggested this failing was the greatest-"ain't got no car."

"And . . . Daigan? You know that's my main concern."

"My first thought is that Alexis is bringing that boy around people he shouldn't be around, you know, but ain't nothing I can do about it 'til I got definite proof. But, uh . . ." He hesitated for a minute, then told the nurse that he had caught Alexis and the young man together.

"You saw?" Luwana asked, uneasy.

"My own eyes."

"James, did you react? Maintain . . . composure?"

"I retained my composure, Miss Luwana, I did. It was hard but I did."

"Just get up, get out?"

He nodded.

"Takes a big man, James," she said, exhaling. "Takes a big man."

Tears filled the man's eyes. "I don't know what happened," he said. "I'm moving out today. Dude probably up in there so I got to go."

"But you have to work out some arrangements, James. Because whatever happens, Daigan still needs you to be the dad."

"I know, I will," he said, in a tone that said he wouldn't, and as he rode off Luwana shuddered. She tended to think of a given child's circumstances as the product of many generations; sometimes, though, the speed of change stunned her. In the time it took to smoke a cigarette, children could be stripped of their fathers. "And in the middle of this is the poor . . . Daigan," she said as she pulled back onto the roadway, "and I can't talk to Alexis, can't see where her head is at, I just . . ." She took a wrong turn, braked at a dead end, and rested her forehead on the steering wheel. "I don't know what I am doing."

Then she sat up straight, shifted into reverse, and repeated the word she'd just said to Daigan's father: "Composure. Composure."

Over the winter, Maggie had stopped taking her hepatitis medicine, as it made her too tired to work. Jose may have contracted the disease as well, but had decided that ignorance was preferable to treatment. Luwana had ruled out ignorance in the case of their daughter, however, and arrived at the house one stormy afternoon to hear the results of the toddler's test.

"It's all messed up," Maggie informed her. "We have to do the test over, but I don't know why-maybe they don't tell me stuff because they think I'm a kid."

"You are a kid," Jose snapped at Maggie. He was staring at her from the far end of the room, a black look in his eyes. When their one-year-old daughter ambled toward him, he scooped her up and began to sing a Metallica song into her ear:

I have lost the will to live Simply nothing more to give There is nothing more for me Need the end to set me free.

"Look," Luwana said, temporarily ignoring the domestic drama. "You guys have got to step up, make the doctors explain. Never leave that office until you understand what's going on, even if you have to say, 'Let me see the records'-they're your records, because Maia is your baby. If she's sick, you're going to have to fight for her, and you're going to have to have the information down." Luwana wrote for a minute in her notebook, then looked up. "O.K., I'm all ears: What is up with you two? And Maggie, what's the deal with the hair?"

The deal with the hair was that Maggie had dyed it black with two platinum skunk-streaks, because skunky was how she was feeling. "It's over-we're not getting married," she told Luwana. "I just blew up my life, right there." Jose nodded, leaving Maggie to explain: how she and Jose had fought, and how she'd had sex with one of his friends; how the next day, Jose's high-school classmate tipped him off, and the guilty friend had proffered the details. Jose had promptly abandoned his cleaning-crew job, stopped his financial contributions to the household, and was moving out. Maggie's mother sat behind the couple, listening with her head in her hands. She'd been working sixteen-hour shifts to compensate for the lost income; still, her bank account was overdrawn.

"The pressures," Maggie said miserably. "The men come at you, and when they get what they want they don't like you for it. I mean, I know that's how it works. And I know that Jose is the person I want to marry-I wanted the three of us to grow up together."

"Well, I don't do forgiveness," Jose said. "And I don't do nice, either. Maybe logical, maybe even humane. But nice doesn't help for nothing in this world."

Luwana immediately set out to discourage Jose from doing what Daigan's father had done: abandon the baby along with the mother. "You can't take this anger out on Maia," she told him with some heat. "This girl has bonded hard with you-you see it, you hear her call you Daddy. And if she has hepatitis it's only that much more important that you keep the bond strong. She is going to need both of you for a long, long time."

"She's a smart girl," Jose said, rubbing his forearms and looking at his daughter, who now stood in an open cupboard blowing kisses around the room like a film star. "We're trying to keep it from her but I think she already knows. I mean, I'm not thinking straight, all I can think about Maggie is bad names. But if I let myself get angry . . ." He paused, then concluded, "Well, that would be it."

"When we have a child, sometimes we feel like being a parent, and sometimes we don't," Luwana said. "And when we don't feel it we act our way through it, because Maia is no sweater you bought at Wal-Mart and change your mind about." There was a silence then, and Maggie looked away. Atop the cupboard was an old photo of Maggie in eyeglasses donated by the Lions Club-"back when I was ten and nerdful and smart." If she had it to do over, she wouldn't have brought Maia into the world and tried to make a family with Jose. But this belated realization made her feel more ashamed than she already felt.

"So fake it," Luwana said, "starting now." She hugged them both, then ushered them out into the storm. "No point in postponing Maia's test," she said by way of goodbye. "Sooner we know if she's sick, the better we plan."

Maggie drove to the hospital, tense and wincing. Rain pummelled the wild irises that had come into bloom on the roadsides, traffic was slow, and other drivers were being hard on their horns. "You were the coolest," Jose hissed into her ear, mindful of what their daughter was overhearing. "You liked my sports, my music, my video games, and then you went and acted like any other stupid girl . . ." By the time they arrived, they were sick of the argument and each other, and they refocussed their attention on Maia. As the baby had her blood drawn, they hovered over her, declared her brave, exclaimed over a Sesame Street Band-Aid. Then they went their separate ways: Jose with Maia to hang out at his parents' house, and Maggie to a week of double shifts at work.

In the month that followed, the girl's janitorial specialties, "garbage and floors," brought her almost unsettling comfort; it was only when she'd put up the mops that Metallica's "lost the will to live" song began to run at high speed through her mind. There was a chance that Luwana could help her get her head straight about sex and win Jose back. But there was little chance that their daughter was going to have a normal life. The test results had confirmed it: Maia's liver was already damaged by hepatitis, and the odds were one in four that she would develop potentially fatal complications.

When Maggie was seven months pregnant, Luwana had asked her to write down the qualities she hoped to pass on to her daughter. "How to be a lady," Maggie wrote first, and then "What love is." She wasn't thinking then about the worst parts of herself, and how those, too, could be transmitted.

In the summer of 2005, the Census Bureau reported that poverty had increased in the United States for the fourth straight year; and the Nurse-Family Partnership produced an empirical snapshot of the one thousand mothers and children in Louisiana who had finished the nurse-visiting program. By some measures, the nurses' efforts seemed to have been trumped by local custom: only a third of the mothers had forsaken formula to attempt breast-feeding, for instance. Other findings were more encouraging, though. By the time their children turned two, almost sixty per cent of mothers over twenty were working, and forty-one per cent of those who had started the program without a high-school diploma or equivalency degree had one in hand. And though it was too soon to determine whether their children's intellectual capacities had been strengthened, one of the study's findings was suggestive. Thirty per cent of toddlers had scored in the top quartile of a national test of language development. But Luwana couldn't help thinking of the mothers and babies who hadn't flourished, and the battle of wills she was now losing with Alexis.

Luwana had pushed Alexis to support herself instead of counting on men, and in July this wish was realized. The teen-ager took a full-time job as a short-order cook, earning six dollars an hour. And while her latest lover didn't have a job, he didn't have a criminal record, either, and sometimes babysat while she worked. But then there was Daigan: a jolly ten-month-old with eyes that missed nothing and a body so large that he was unable to crawl.

As Luwana held him, her trusty mind-trick-would this scene have been worse without me in it-didn't provide the comfort it sometimes did. "I think she'll keep making small changes in the months ahead, but now I don't expect a transformation," Luwana said of Alexis. "She doesn't want for herself what I want for her, and that's something I have to make myself accept."

Alexis concurred with the nurse's forecast, and decided to quit the program. One evening in August, she sat on the couch and looked at Daigan, who was on the floor in a "Motor Speedway Heavy Duty" T-shirt, staring back. "Luwana really cares about me," she said. "And she's helped me a lot-I learned stuff, like how old they gonna get and what they gonna go through and how they gonna grow. But what Luwana says to do-well, basically, I just do it my way." She had recently miscarried her new boyfriend's baby, she said as Daigan emitted a single high shriek. As she reflected on the miscarriage, sadness softened her face, until another thought hit her, and she broke into a beautiful smile. Her boyfriend was eager to try again, she said. "And next I want a little girl."

A few days later, Luwana arrived at Maggie's house to find that a tropical storm had blown off part of the roof. She scarcely noticed, as she had come to celebrate a battle that she'd won. The day before, Maggie had returned to high school. The girl spiritedly shared some newfound knowledge: "In Rome, the invaders came and tried to wipe out all the intelligent people-all the teachers and libraries-because they didn't want the competition, but then everyone ended up kind of stupid." Jose, who was with her, then took her hand. Together, they informed Luwana that decisions bigger than high school had also been made. Jose was joining the Marines, and he and Maggie had decided to marry. In the telling, their mouths were straight lines. Love and patriotism were not much on their minds.

"I'm less nervous about Iraq than I am about marrying Maggie," Jose told the nurse as he and Maggie took turns pushing the talkative eighteen-month-old Maia around in an empty diaper box. Since they lived in a community with a particularly high death rate in the war, Maggie saw the Marine Corps and marriage as equally distressing propositions. But the couple had made a hard calculation, and there were two things they wanted for their daughter that they didn't know another way to get: good, possibly life-extending medical care and a habitable dwelling in which she might grow up.

A few days later, Katrina came through the swamps, damaging homes but sparing lives. As Luwana cared for injured New Orleaneans in a triage unit, Maggie, Jose, and their families undertook a familiar ritual in this hurricane alley: taping together broken windows, eating from cans, and waiting for the electricity to return. One day, Maggie, whose skin was mottled with poison ivy after bundling up fallen branches, realized that there were just enough food stamps left to buy a wedding cake at Wal-Mart.

The ceremony would take place on a building site that Maggie's father mowed for pocket money. There was a gazebo on the field and, one rainy evening shortly before Jose left for boot camp, a silver cloud of mosquitoes as well. The wedding guests assembled, the shrimpers among them watching the sky as they slapped and scratched. Heat lightning flashed; somewhere, new storms were gathering, and the Gulf waters felt to them weirdly warm. They sensed another hurricane, Rita, which would arrive the following week and obliterate thousands of fragile dwellings in Luwana's territory. Among the homeless would be Maggie and Maia.

But now the bride, waiting for her mother to find the tape with the wedding music on it, leaned into a mirror to see if her tube of lipstick had met its target despite her shakes. She'd seen enough movies to know that such trembling was normal, and that these moments before the vows were for dreaming. "Three bedrooms someday," she said as Luwana came to escort her across the field. "And two baths."

Afterward, Luwana tried to feel optimistic-to see, in the tough choices of two teen-agers, real hope for an impoverished American child. And if the sacrifice and exertion required to secure that tenuous possibility struck her as outsized, well, she was a practical woman, and she had a fresh obligation in a hamlet named Cut Off-a newborn whose parents had met in court-ordered drug rehab and then broke up.

"So beautiful, Miss Alaysia, even when you cry," Luwana sang off-key to Cut Off's newest resident, a dark-haired girl in a soiled white dress. "Real tears already? Baby, you're quick! Now Mama, are you reading to her yet?"