February 6, 2006 -- Recently the mainstream press has run very positive stories about the Nurse-Family Partnership. The Partnership is a cost-effective nationwide program in which nurses make extended pre-natal and post-natal home visits to improve the health and wellbeing of poor first-time mothers and their children. This week's issue of The New Yorker included the extensive, moving "Swamp Nurse," by respected poverty journalist Katherine Boo. The piece describes the awesome work of rural Louisiana nurse Luwana Marts, with contextual information about the Partnership and its effectiveness. On January 16, The Philadelphia Inquirer ran a far shorter article by Marie McCullough taking a similar approach. It profiles impressive local Partnership nurse Sara Eldridge, with comparable background information. Both pieces are great showcases for the value of the nurse-centered program. And they offer powerful portraits of the individual nurses, who question, teach, and cajole their patients toward better lives, despite huge obstacles. Sadly, neither writer seems aware that the Partnership fits easily within the long tradition of holistic, home-based nursing care. So readers may assume that the idea that the "nurse-visitors" can improve maternal-child health originated with Partnership founder David Olds, a developmental psychologist. Readers may not even see what these nurses do as really being nursing. And the pieces fail to convey how much the nurses' success is due to their nursing education and skill, not just Olds' program design, or the nurses' personal attributes, trusted image, and on-the-job experience. Even so, the articles--especially Boo's perceptive New Yorker piece--ably present the Partnership nurses as skilled professionals excelling at an important job. We commend those responsible.
McCullough's piece, "Proof Positive," focuses on Partnership nurse Sara Eldridge's care for 16-year-old LaTara Johnson and her five-month-old daughter Zahara. As part of the voluntary program, Eldridge will visit Johnson at home every few weeks until the baby is two. At one visit the reporter observes, Eldridge "gushe[s]" about the baby's development. But she also "lecture[s], question[s] and praise[s]" Johnson, discussing her grades, her job, her health practices, the baby's feeding and care, and how Johnson handles the stress. The nurse presses Johnson on her plans for future, which include not having another baby too soon; that would threaten her ability to care for Zahara and become self-sufficient. The baby's father, who lives down the street, joins the discussion when he arrives. This is a good portrait of a nurse providing vital psycho-social care and holistic health education.
The piece also describes a "former client" of Eldridge's, Terri Caddle-Boston, who was raised in foster care and got pregnant at 17. Five years later, she and her daughter's father are married and employed, and she is reconciled with her mother and set to enter a "nurse training program." Caddle-Boston describes Eldridge's professional care as "counseling, friendship, and finding someone who cares about your feelings."
The piece also suggests that nurses are eager to work for Partnership programs (though it does not mention that they tend to earn much less than the average registered nurse). It quotes University of Pennsylvania nursing professor Kay Kinsey, who directs the Philadelphia program, as saying that many nurses have "recruited themselves" because they are tired of being "at the other end of the problems--being in the hospital, patching up the kid with the gunshot wound." Eldridge, the daughter of a Jamaican public health nurse, reportedly "loves" to help young women figure out what matters most and what they want in life. Eldridge says the patients "need somebody in their corner saying, 'You can finish high school, you can breastfeed, you can quit smoking, you can get a job.'"
The Inquirer piece reports that the Partnership's national office is in Denver, but each local program arranges its own funding and administration, through various mixes of governmental and charitable sources. The piece focuses on the program's proven benefits, which it suggests are "rare" for a social program and may be a "model for others." Partnership programs, which now serve 20,000 families in 20 states, have been shown by "[r]igorous, long-term studies" to improve young mothers' parenting skills, education and employment rates, while reducing child abuse, welfare use, arrests and substance abuse. Kids, in turn, have fewer "serious behavior problems." The piece notes that one 1997 study showed that for every dollar spent on the Partnership, the government saved four dollars through higher employment and lower spending on public assistance and crime. Another study reportedly found the Partnership to be the most cost-effective of eight home visitation programs studied, saving roughly three dollars for each dollar spent.
David Olds, who now directs the University of Colorado's Prevention Research Center for Family and Child Health, has reportedly been testing the program model since the late 1970's. The piece stresses that the program actually resisted growing too quickly or accepting government funds until Olds and his colleagues felt that it had been shown to be effective. Olds himself seems focused on carefully mapping the limits of the program, noting that it is no cure for poverty, and still a "work in progress" that can be improved.
The piece notes that home visits have long been part of "social service programs." But the Partnership is "more effective" (and "more costly") because it relies on nurses, whose "medical background" and "positive image" give them an edge. (Olds says that social workers are viewed as "the people who take your baby away.") The piece notes that Partnership nurses get "extensive training, close supervision," and limited caseloads. Although the piece did cite comments earlier by the nursing professor who directs the local program, the phrasing of these last points may suggest to readers that nurses do not have significant relevant training simply by virtue of being nurses, or that they need close supervision to be effective. It may also suggest that what the Partnership nurses are doing isn't really nursing, but some tangential thing designed solely by David Olds.
However, regular home visits have long been part of the holistic vision of modern nursing, including in the area of maternal-child health. For instance, in 1925, nursing pioneer Mary Breckinridge founded the Frontier Nursing Service (FNS), in which nurse-midwives on horseback delivered high quality pre-natal, childbirth, and post-natal care to poor families in rural Kentucky. The FNS model has influenced health professionals around the world and it is still going strong today, with SUVs reportedly replacing horses. (And lay midwives have provided vital home-based maternal and child care for centuries, as a recent Smithsonian exhibit about African-American midwives made clear.) The Partnership is not really a revolutionary innovation in nursing practice. In fact, it sometimes seems that nurses' health ideas and practices become worthy of note (and funding) only when they are embraced by members of respected, traditionally male professions like psychology.
Katherine Boo's New Yorker piece makes similar points about the Partnership's overall design and the evidence that it works. But the article goes much deeper in analyzing why the program exists and the "preposterously difficult assignment" the nurses confront. Boo suggests that the program is based on a recognition that current social institutions aimed at helping a child of the poor (e.g., schools) are inadequate. The real strategy here to help that child is the intrusive one of "building for him, inside his home, a better parent." Oddly, Boo's piece seems to suggest that the Partnership is really focused on the kids, while the Inquirer story presents it as being mainly about the mothers. The Partnership site says that the goal is "producing enduring improvements in the health and well being of low-income, first-time parents and their children" (emphasis added), which makes sense since those two aims are so closely related.
Boo goes into more detail about Olds' background in pioneering the program in the poor rural community of Elmira, NY, in the late 1970's. She describes his constant (and at times amazingly self-critical) efforts to improve it since then, partly through extensive reporting by the nurses in the field. The Program children in Elmira were less likely to have been abused than those in a control group. And their mothers were more likely to be employed, off public assistance, and in stable relationships. Later pilot programs elsewhere suggested other benefits, including better academic performance by the children. At all sites, mothers in the program had fewer kids and more space in between them. Boo discusses a study showing the cost-effectiveness of the program. And she describes an "empirical snapshot" of the Louisiana program suggesting that it has improved participating mothers' educational and employment situations, and possibly their kids' intellectual capacities. Boo shows how unusual the program is in resisting the "fade-out" of benefits that many social programs experience over time, noting that the Elmira kids were far less likely to have been arrested even 15 years later. But she also recognizes the full magnitude of the problem the Program confronts: though it now serves about 20,000 kids annually, that is less than 1% of the 2.5 million lower-income children in the U.S. That could certainly be described as nurse short-staffing.
Despite Boo's far deeper analysis of the Partnership, her piece has some of the same problems as the Inquirer article. A reader could easily conclude that what the nurses are doing here is a new invention by Olds. The New Yorker piece fails to mention any nursing precedents, or to suggest that what Luwana Marts is doing is in many respects the kind of public health nursing that nurses have traditionally done and continue to do, despite an apparent reluctance in some quarters to adequately fund this vital work. For instance, recent New York press pieces have highlighted the important work of short-staffed Suffolk County public health nurses, a good deal of which involves home care, teaching and advocacy for the same patient population as the Partnership nurses. The New Yorker piece notes at one point that the nurses have "medical expertise" of interest to pregnant women, and that it is one reason Olds chose them to be part of the program. But in an interview with Boo posted on the New Yorker site, the writer also suggests that in Elmira, Olds "trained some nurses in prenatal care and infant development," as if he had started with a blank slate.
In fairness, in that same interview Boo makes clear that the Louisiana nurses turned out to be "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." She stresses that the nurses do not simply help poor mothers "change diapers," but that they "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." The individual nurses can't change systemic social imbalances, but they can empower patients to fight for their kids, for instance, by demanding to see medical records.
In fact, all this is at the heart of the nursing tradition, with its focus on holistic care and patient advocacy. But a number of subtle elements in Boo's piece reinforce the sense that the nurses' success is really more a function of their personal backgrounds (Marts notes that many are working in "the context of our own memories"), their natural aptitudes, or their experience in Olds' program, and not so much their unique nursing training and approach. In her online interview, Boo notes that Marts is good at her job because she's a "shrewd student of human nature." She also quotes' Marts supervisor, nurse Claudette McKay, as making the interesting observation that Partnership nurses have to actually "like" their patients to excel. That may all be true, but again, it's not the whole story.
Make no mistake: Boo is an amazingly astute observer of Marts' specific work, and she generally does a good job of avoiding stereotypes. She makes clear that the nurses report to the tough, seen-it-all McKay. And she never suggests that the nurses' work somehow revolves around physicians; indeed, physicians are essentially absent from this story, as they were from McCullough's Inquirer piece. However, when Boo pulls back to make more general statements about the nurses, a few troubling assumptions do slip in. Early on in the piece she describes Marts as a "professional nurturer." Obviously some aspects of nursing could be compared to nurturing, but the maternal associations of this term are unlikely to inspire decision-makers to allocate the kind of resources a modern profession needs. Likewise, Boo's references in the online interview to the nurse-visitors as "evangels" and "social crusaders" do not send the right message about a profession that has spent decades fighting a stereotype that it is composed of "angels," unskilled spiritual beings who do not require the material and other support that ordinary humans do.
But these concerns do not diminish the unusual power and insight in Boo's description of the care of Luwana Marts, which occupies most of the piece. Boo chooses to focus on Marts' work with two mothers and their infants. She accompanies Marts on visits to these families over an extended period. On this canvas, Boo draws a convincing picture of poor young mothers struggling to cope with severe adversity and dysfunction, and of a tenacious, savvy nurse who marshals a range of technical and psycho-social skills to give the imperiled families a better chance. "As [Marts] moves through a household, giving advice about routine-building, 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 great-grandmother getting high in a tent behind the house." Once a "poor, pregnant teen-ager in these swamps" herself, Marts emerges as one of the most adept and inspiring nurses we've ever seen profiled in the mainstream media.
Alexis Theriot is one of the two mothers in Boo's account. Alexis is a teenager who, after seeking Medicaid for her impending delivery of son Daigan in late 2004, "ended up with both the Medicaid and Luwana" Marts. Alexis is a reluctant patient, viewing Marts, as some mothers do, as "a spy in the house of maternity." Even so, Marts reportedly persuaded Alexis to stop drinking and smoking during pregnancy, and to get prenatal care. Boo tells how Marts begins a discussion with Alexis with a "practiced tranquility while scanning a body in a playsuit for signs of damage." Marts counsels Alexis about her relations with Daigan's father James, a tugboat worker who will be returning home the following weekend. When Marts hears that James will be expecting to have sex with Alexis, who has not healed from childbirth and is not using contraception, she says: "Keep your legs closed...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?" Alexis responds: "Miss Luwana, maybe you can write me an excuse note, like for gym?" Marts probes and teaches Alexis about her care for Daigan. She goes into everything from the child's language development to the best ways for his mother to handle the stress of childrearing. Luwana combines interaction with Daigan with praise for his mother, "using the high frequency tones that babies hear best": "See, your mama is getting it...She's surely going to figure you out." Marts sings "Clementine" to Daigan; Alexis "studies" this interaction with her son.
Marts's focus on one day is "infant attachment," "a topic she tailored to fit Alexis' limited attention span." Luwana tells Alexis: "A funny thing about the axe murderers...usually something missing in the love link." This gets the attention of Alexis's sister's boyfriend, who is chopping a chicken nearby. He and his white supremacist tattoos have just been released from prison. Nevertheless, he tells the African-American Marts that he wants to hear about this too, because his own child is "horrible...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." Marts responds: "You hit a two-year-old?...You teach him how to fight and are surprised when he turns around, starts fighting you?" Then, "fix[ing] her stare" on Alexis, Marts describes the "love link" as 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...It's on you now to comfort him, earn his trust, because that's how Daigan is going to learn how to love."
Alexis is not destined to complete the program. But Boo still notes in the online interview that she was "amazed" that Marts was able to stay involved with Alexis and Daigan as long as she did. Even though the Partnership database will record the case as a "failure," Boo notes, Marts's "supervision" probably improved Daigan's first year of life. Indeed, Marts's arsenal seems vast. At one point, Boo notes that Marts had managed to turn Alexis's own sister into an "informant," and thus learned that Alexis and James had been "brawling." Marts spots the "strapping" James down the road on his motorcycle, and chases him down in her car. She learns from him that he has caught Alexis with another man, apparently a wanted drug taker, on parole, with no job. Marts makes an effort (apparently futile) to keep James from leaving the picture. Later, Marts gives Boo a kind of nurses' lament about Alexis: "She doesn't want for herself what I want for her, and that's something I have to make myself accept."
Maggie Lander, 17-year-old mother of Maia, is a different story. Not in terms of hardship: Boo reports that when Marts first met Maggie, she was "an intelligent, underfed 10th grader in her second trimester who was sick with untreated hepatitis B and who was also trying to care for her mother, who was bedridden and weighed eighty-two pounds." But after a year of Marts' "campaign against hopelessness," baby Maia is an "exuberant babbler," Maggie's mother is working with her daughter at a cleaning company, and Maggie is engaged to Maia's father José. Maggie has become "a diligent student of child-development technique," spending so much time on the materials Marts gives her that she is annoying José. Marts reportedly sees in Maggie "that caged bird singing," and "privately [gives] Maggie her highest praise: 'The girl's an overcomer.'"
Marts pressures Maggie to return to school, but worries that she lacks adequate support structures. At one point, Luwana studies Maia at play. When Maggie stops her daughter from crawling away because the house "isn't safe," Luwana stresses that the infant needs to explore and become independent. Luwana urges Maia to walk, and Maggie protests, saying the child is not ready. Luwana raises her eyebrow and elicits a laugh from Maggie; "[i]t was Maggie who wasn't ready." Marts pushes Maggie to be more assertive in "mak[ing] the doctors explain" things like the status of Maia's hepatitis test: "If she's sick, you're going to have to fight for her, and you're going to have to have the information down."
Upon hearing that José is threatening to leave because Maggie had sex with one of his friends, Marts works aggressively to discourage him from abandoning his child as well as her mother. Eventually, Maggie returns to high school, which Boo describes as a "battle that [Marts] won." Maggie also marries José, who decides to join the Marines, in an effort to provide his hepatitis-stricken daughter with "possibly life-extending medical care and a habitable dwelling in which she might grow up." Shortly after the wedding, which Boo says features a Wal-Mart cake financed with food stamps, Maggie and Maia are left homeless by Hurricane Rita.
Well, some might ask, if all of this is so much a part of the nursing tradition, why was the Nurse-Family Partnership founded and led by a non-nurse? Why are we reading articles about how it fell to a developmental psychologist to decide that nurses were a good group to plug into his vision of how to improve the health of poor families? Naturally, it would probably not occur to most journalists to pursue this. And neither Boo nor McCullough seems to see anything odd about it--there's nothing remarkable about a classic group of perceived subordinates being directed here or there by people with PhDs. But surely this kind of program has occurred to many nurses caring for patients like Maggie and Maia. Thousands of nurses are doctorally-prepared scholars just like David Olds. And as we have seen, nurses like Mary Breckinridge have done something comparable to what Olds has done here. It's hard to avoid the sad conclusion that, despite all our talk of nursing autonomy and holism, nurses still seem to lack the power and/or initiative to help society fully utilize their own practice.
But tomorrow is another day. Boo ends her well-written piece by describing Luwana Marts' struggle to stay hopeful about patients like Maia, leaving readers with an image that captures the "swamp nurse"'s relentlessness:
And if the sacrifice and exertion required to secure [hope for Maia's future] struck [Marts] as outsized, well, she was a practical woman, and she had a fresh obligation in a hamlet called Cut Off--a newborn whose parents met in court-ordered 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?"
The article "Swamp Nurse" by Katherine Boo, published in The New Yorker on February 6, 2006 can be accessed online at the New America Foundation.