Hillary Clinton – Primary of One

A guide to the least contentious election of our time.

Jay Brown is a blunt-talking doctor from Ames, Iowa, the kind of guy who believes the biggest threats to the republic are the Koch brothers, Rupert Murdoch, and the corporatization of politics. Back in 2007, he signed up as a precinct captain for Barack Obama with one stated goal: to “undermine Hillary Clinton,” whom he referred to simply as “the nemesis.” He thought she had too little experience to be president and that her judgment on Iraq had been terrible. “I’m pleased to report that the Ames 2-2 precinct went heavily for Obama, who got four delegates,” he told me last month. “We shut Hillary out entirely.”

This time around, Brown talks like a man in the market for another crusading liberal, perhaps Elizabeth Warren of Massachusetts. “Wall Street would be fine with a Clinton administration. I don’t think it would be fine with a Warren administration. It would send a really deep chill,” he explained. And yet, despite all the personal history and the ideological grudges, Brown is unequivocal about whom he’ll support in 2016. “I’m a booster of Hillary Clinton,” he said. “I would go so far as to say an ardent booster.”

As it happens, Brown is not an outlier among plugged-in liberals. Seven of the ten former Obama precinct captains I contacted said they were enthusiastic about Clinton (and an eighth said she was slowly coming around). Harry Enten of FiveThirtyEight has observed that 13 of the 21 U.S. senators who’ve already endorsed Clinton hail from the left side of the party. A Democratic fund-raiser confided to me that it’s highly unusual to meet a big donor who is pro-Warren but down on Hillary. So much so that he was actually surprised when he encountered such a person several weeks ago. “I haven’t heard that very many times,” says the fund-raiser.

Amid Clinton’s miscues while promoting her new book, widely
seen as a test-launch for 2016, the media has been quick to revive
memories of 2008. A Politico article noted that her defensiveness
in response to questions about her wealth, gay marriage, and
Benghazi “reminded liberal Democrats who’ve viewed her warily
of what troubles them about her.” MSNBC followed with a segment
wondering if Clinton was the Democrats’ Mitt Romney—someone
“kind of tone deaf and unrelatable,” who “exuded competence but
no core belief.”

There is maybe some truth to those claims, but when you look
at the polls, Democrats are more enthusiastic about Hillary Clinton
than ever. Her favorability rating within the party stood at 90 percent in the latest Gallup poll, versus 81 percent this time eight years ago. A Wall Street Journal survey of Democrats during the book tour found that their opinion of Clinton has vastly improved since late 2007. Many more Democrats now consider her knowledgeable (88 percent versus 76 percent), compassionate (80 versus 69), easygoing and likeable (67 versus 49), aligned with them on the issues (76 versus 61), and honest and straightforward (75 versus 53).

More interestingly, Clinton’s popularity turns out to be highest
in places you might least expect. She consistently performs better
among liberals than among moderate and conservative Democrats,
though it was the former who deserted her six years ago. A recent
CNN poll found that only 11 percent of Democrats prefer a candidate who is more liberal. Put it all together—the numbers, the
enthusiasm, the unlikely converts—and it’s a striking turnaround
for a candidate who, when her opponent famously proclaimed her
“likeable enough” in 2008, discovered that less than half her partyagreed. And the reasons behind this resurgence tell us about more than just 2016—they reveal something fascinating, even downright profound, about the Democratic psyche.

A few days after Obama announced his pick for secretary of state in 2008, a cringe-worthy photo turned up on Facebook. It featured 27-year-old Jon Favreau, the incoming president’s top speechwriter, groping the breast of Hillary Clinton, albeit in cardboard cutout form. During the primaries, the Clinton camp was quick to pounce on such boorish behavior, and the president’s aides steeled themselves for some well-deserved blowback. But it never came. Clinton’s communications aide Philippe Reines sent an e-mail to a reporter joking that “Senator Clinton is pleased to learn of Jon’s obvious interest in the State Department, and is currently reviewing his application.” Clinton herself, according to the book HRC by Jonathan Allen and Amie Parnes, quipped to Favreau that, “I haven’t seen the picture yet, but I hear my hair looks great.”

Talk to Obama veterans about Clinton’s first few months in office, and one memory stands out: She plainly embraced the role of sidekick. She devoured White House briefing material. “Hillary Clinton would walk in with the thickest binder on the table,” says a former Obama staffer. She mastered the art of the small gesture, plying Obama aides with personal notes and mementos. One received an official State Department sling for his injured arm, Allen and Parnes report. Day in and day out, she was unfailingly gracious. Among the less glamorous duties of a Cabinet secretary is waiting outside the president’s office when he’s running late. “No one will judge you if you sit there and answer e-mails on your Blackberry,” says Katie Johnson, Obama’s former personal secretary. “She did not do it. . . . She was very friendly and warm. She talked to people.”

Two other factors dovetailed with Clinton’s personal efforts at reconciliation. First was the remarkable overlap between her and Obama’s worldviews, which made them natural allies. “The 2008 primaries were emotionally intense, but ultimately the policy disputes were not that significant,” says Ben LaBolt, a former Obama press aide. “This wasn’t a grand dispute about where the Democratic Party was headed. . . . That made it easier [to come together].”

The second was Team Obama’s realization that it had enemies, even inside the administration, and they didn’t look much like Hillary Clinton. “There were never big bad damaging leaks from the State Department,” says another former White House aide. “Obviously her interests were front and center. But they were also motivated by making sure the president succeeded. I don’t know that that was the case at the Pentagon.”

The logic of Clinton’s rapprochement with the Obama crew also explained her rehabilitation across the rest of the party. Clinton’s willingness to join the Cabinet boosted her favorability rating more than 10 points among Democrats between late 2008 and early 2009. And with the party largely united on everything from tax cuts to entitlements to climate change to health care, there was no ideological rift to come between her and any particular faction. “Democrats are less polarized even than we were in 2006–2008, when our involvement in Iraq was front and center,” Clinton’s former presidential campaign strategist, Geoff Garin, told me.

Above all, as the Republican Party became more crazed and abusive, even previously skeptical Democrats saw Clinton differently, a pattern that has recurred throughout her career. “There’s a respect for her as an accomplished senior player who stood up to right-wing attacks,” says Ilya Sheyman, head of the liberal group MoveOn.org Political Action.

Unfortunately for Clinton, the years leading up to 2008 were one of the rare moments when she didn’t benefit from this dynamic. A Republican controlled the White House, making the Clintons less likely to arouse the right’s conspiratorial mania. Worse, because that Republican had been uniquely divisive, many Democrats had reservations about politicians associated with the same shiv-wielding tactics. “They worried that as a standard-bearer she might be polarizing,” says Larry Grisolano, who oversaw the Obama campaign’s polling in 2008.

But in the last few years, with Democrats in power and Clinton emerging as Obama’s chosen successor, the assaults from Republicans—on her age, her health, her central role in a variety of imagined conspiracies—have escalated, prompting a return to ’90s-era solidarity. “The things that have been thrown at her have never been thrown at any other candidate or spouse,” says Bonnie Adkins, another former Obama precinct captain, who took pride in taking down the high-handed Clinton campaign in 2008. “I’m more concerned with her personal mental heath. Not that she has mental health issues. Just how she deals with it. It’s more empathy than concern.” Adkins says she feels a particular connection with Clinton as a woman: “If you haven’t had a baby yet, you haven’t done anything.”

The upshot of all these developments is a preposterous level of support. Since she joined the administration, Clinton’s favorability rating among Democrats has never dropped below 88 percent, according to Gallup. (By comparison, Joe Biden’s favorability numbers have generally hovered in the low-to-mid 70s.) Her hold on the Democratic nomination looks unshakable.

Of course, Clinton’s hold on the 2008 nomination also looked unshakable, just before she fumbled it. Faced with the right combination of opponent and issue, even the strongest candidate can suddenly become vulnerable. This time around, the identity of the challenger is hard to predict, but there’s at least one issue that could cause Clinton real angst: economic inequality.

On the surface, inequality would appear to be yet another question on which Democrats agree. A 2012 Pew poll showed that 92 percent of them believe “the rich just get richer and the poor get poorer,” up from 84 in 2009. Obama has spoken out on the subject several times, including a high-profile speech in Osawatomie, Kansas, where Teddy Roosevelt delivered a similar warning in 1910. Clinton recently signed onto the consensus herself, delivering a major speech on inequality at the New America Foundation in May.

But it turns out inequality isn’t one but two issues that are often jumbled together: The first is the plight of the poor, working poor, and middle class, who are weighed down by stagnant wages and high unemployment. The second and potentially more explosive is the gap between the ultra-rich and everyone else, which has expanded to Gilded Age levels over the past few decades. Gallup has documented a huge spike in the percentage of Democrats who are dissatisfied with the “size and influence of major corporations.” Pew found that, as of late 2011, 91 percent of Democrats believed there was “too much power in the hands of a few rich people and large corporations.”

Clinton has the credibility to address the first set of problems, whose solutions include better education and jobtraining, a higher minimum wage, stronger labor unions, and a more generous safety net—some of which voters associate with her husband’s administration.

On the second question, however, Clinton’s reÅLsumeÅL is less compelling. Many of her and her husband’s closest economic advisers hail from Wall Street. After hiking the top income tax rate in 1993, they cut the capital gains tax in the late ’90s and deregulated the financial sector. Hillary Clinton has spent decades raising enormous sums from executives at Goldman Sachs and Citigroup, and the Bill, Hillary & Chelsea Clinton Foundation, which she joined after leaving the State Department, survives on the largesse of the 1 percent.

On her own time, Clinton has enjoyed several six-figure paydays speaking to corporate executives, including two at Goldman Sachs that netted her an estimated $400,000. And, of course, she has repeatedly struggled to justify all the buckraking, telling Diane Sawyer that she and her husband were “dead broke” when they left the White House. “There’s a lot of vulnerability in the Clinton record going back to Glass-Steagall [the landmark banking regulation her husband mothballed],” says a longtime Democratic presidential operative. “It’s obviously reinforced by this silliness about being broke.” During her recent speech at New America, she only passingly mentioned this second type of inequality. (A Clinton spokesman says she “consciously left the discussion for another day.”)

Yet even this liability seems unlikely to threaten Clinton’s standing in the party. Democrats have become so positively disposed to her that, unlike 2008, when they seized on an issue (Iraq) and worked back to her character (cynical), they now begin with her character (moral, honest, straightforward) and work back to the issues.

In 2004, Graham Gillette, an Iowan who once worked for the elder George Bush, supported John Edwards after hearing his “Two Americas” refrain on inequality. He signed up as a precinct captain for Obama four years later because he was “enthralled with his magnetism and message” and had the lifelong Republican’s skepticism of Hillary Clinton. But in 2016, he is all in for Clinton, and inequality is a big reason why. “She has the credibility to address these things today that she didn’t eight years ago,” he told me. “She is, of anybody out there, Democrat or Republican . . . uniquely positioned to talk about this topic. I do think it’s the most important topic of the campaign.” It’s not that Democrats like Gillette support Clinton despite her positions on some key issues. It’s that, precisely because they are so favorably disposed toward her, they assume she must be with them on the issues they care most about.

Granted, under most circumstances, there is a reliable method for outing a front-runner who may be somewhat at odds with the party, even if voters are well-disposed to her. It’s called a primary. The more scrutiny the front-runner receives, the more voters learn about her actual views, and the less they fill in the blanks with glowing assumptions. But what’s so unusual about Clinton’s standing is that, unlike 2008, it’s almost certain to hold up even against a perfectly positioned challenger—say, Elizabeth Warren, the most beloved economic populist in the country.

To see this, just consider the liberal Democrats who are already aware of Clinton’s ties to the 1 percent and of Warren’s efforts to rein in this group’s political power—a reasonable proxy for how ordinary voters might react as they learn more about each candidate. While just about all of the liberals I spoke with admire Warren, and still want to see the Washington establishment upended, Obama has soured most of them on the idea that a politician can pull it off. “I will tell you, as much of a dreamer as I had been, I’m now somewhat jaded about Obama,” Jay Brown told me. “Clinton has impressed me with her tenacity and capacity for compromise.”

Or consider the case of Mark Schmitt. Back in 2007, Schmitt wrote an influential essay in The American Prospect arguing that Obama’s “theory of change” was superior to Clinton’s, which mostly accepted the status quo and aimed for marginal improvements. Schmitt currently runs the New America Foundation’s project on political reform—basically, the wonk-world’s vigilante against the influence of the 1 percent. If anyone should be inclined to support Warren and be skeptical of Clinton, it would be him. Yet he too is what Brown would call an ardent Clintonbacker. “In some ways, the Clinton mode of grind something out, don’t promise transformative change you can’t possibly deliver— that strategy looks a lot sounder six years later,” he says.

One former Obama administration official quipped to me that it’s as if the Democratic Party has finally reached middle age. It’s not that liberals don’t perceive some ideological distance between themselves and Hillary Clinton, at least as they become more informed. Nor is it that they recognize this gap and simply don’t care about it. It’s that, after the somewhat disillusioning experience of the Obama years, many actually consider this gap an advantage for Clinton. Even Grisolano, Obama’s polling honcho from 2008, concedes, “It may be that coming out of this period, where Congress has been so obstinate, so difficult to move . . . that people are looking for someone whose central skill is how to work the power structure.”

So let’s say Democrats’ faith in Clinton is rewarded and she wins the presidency. Here is how the 2016 transition is likely to play out. Having talked about inequality during the primaries, and maybe even the general election, she will feel pressure to appoint economists who know something about the issue. She will pluck a few advisers from the reserve army of liberals at think tanks like the Center for American Progress (home to many former Clinton White House aides over the years), the Economic Policy Institute, and the Center on Budget and Policy Priorities.

But as the transition goes on, liberals will notice a disconcerting shift. They will watch most of the senior posts in her Treasury Department go to alumni of Wall Street. They will see her fill out the top echelons of financial regulators—the Securities and Exchange Commission, the Commodity Futures Trading Commission, the Office of the Comptroller of the Currency—with banking-industry lawyers. They will even notice bankers turning up in agencies with little role in finance, like the State Department and the U.S. Trade Representative. Though any one appointment may be justified— the Treasury undersecretary for domestic finance should probably have a finance background, for example—the larger mass of Wall Street transplants will create a stubborn level of groupthink. Their skepticism toward policies like a financial transactions tax, aggressive prosecution of financial-market crime, and breaking up the megabanks will ensure they never happen.

In fairness, Clinton’s inner circle isn’t exactly plotting some Wall Street coup. Setting aside what Clinton would actually do as president, she and her aides at least perceive themselves as occupying the liberal ground on most economic and financial issues. “It’s not like the Iraq war, where she was a little bit at odds with party, and more of a hawk,” says one former Clinton aide. “Go back and look at the campaign stuff from ’08. It was pretty progressive—on housing, sovereign wealth funds, derivatives.” The basic governing force here is inertia: Our hypothetical transition is simply the likely outcome given her relationships within the most rarefied slice of society.

Progressives have such an easy time conjuring up this banker-heavy scenario that they’ve given up denying Clinton the nomination—which most consider futile anyway—to focus on the more urgent task of boxing her in as president. According to Adam Green of the Progressive Change Campaign Committee, groups like his are planning to spend 2015 badgering candidates about “whether they agree with Warren” when it comes to economic populism. Their plan is, in effect, to deploy the spectral presence of Warren to extract as many concessions as possible.

It’s not a crazy strategy. The mere thought of Warren seems to rattle the Clintons, who are haunted by the debacle of 2008. When Warren’s Senate campaign asked Bill Clinton for help in 2012, he declined to appear in public with her, agreeing only to a photo at a private event that she could distribute. (The former president also recorded a robocall for her and allowed her to send an e-mail to supporters under his name. But the latter was on the condition that she send another e-mail promoting him and the Clinton Foundation after the election.)

Warren herself seems inclined to keep the Clintons on edge. She recently needled Hillary in The Washington Post over her “dead broke” comments and refused to entirely rule out a presidential run. In late April, she wrote an op-ed titled “The Citigroup Clique,” in which she announced her “growing frustration over the concentration of people with ties to the megabank Citigroup in senior government positions.” Though she pegged the piece to the appointment of Stanley Fischer, a prominent economist and former Citigroup executive, as vice chairman of the Federal Reserve, it was interpreted on the left as an effort to block Robert Rubin proteges from dominating a future Clinton administration. “We want to know who is Hillary’s team,” says another progressive activist. “There has to be some kind of conversation between the electoral base of the party and the Clinton family over what it is these people stand for, and, more importantly, who is going to work for them.”

There will almost certainly be a conversation—you might even call it a negotiation—and the left will have some leverage. But, in the end, the idea that progressives can dramatically influence Clinton’s economic team is only slightly less of a stretch than believing they can oust her in the primary. Clinton will find a way to appoint most of the people she wants to appoint, and to pursue the agenda she wants to pursue. That, after all, is what many liberals now find so appealing about her. They just shouldn’t be surprised when a candidate who excels at working the system ends up working them, too.

A Preemie Revolution

Cutting-edge medicine and dedicated caregivers are helping the tiniest babies survive— and thrive.

It’s a safe bet that David Joyce knows more than you did when you were his birth age. That’s not hard, since what you knew back then was pretty much nothing at all. You knew warmth, you knew darkness, you knew a sublime, drifting peace. You had been conceived 29 weeks earlier, and if you were like most people, you had 11 weeks to go before you reached your fully formed 40. It was only then that you’d emerge into the storm of stimuli that is the world.

No such luck for David. He was born Jan. 28—well shy of his April 16 due date—in an emergency cesarean section after his mother had begun bleeding heav- ily. He weighed 2 lb. 11 oz., or 1,200 g, and was just 15 in. (38 cm) tall. An American Girl doll is 3 in. (8 cm) taller. Immediately, he began learning a lot of things—about bright lights and cold hands, needle sticks and loud noises. He learned what it feels like to be hungry, to be frightened, to be unable to breathe.

What all this meant was that if David wanted to stay alive, he’d have to work hard at it, and he has. Take drinking from a bottle—which he had never tried until a morning in late March, at the neonatal intensive care unit (NICU) of the Chil- dren’s Hospital of Wisconsin in Milwau- kee. David had spent every day of his then seven-week life there, in the company of 58 other very fragile babies being looked after by a round-the-clock SWAT team of nearly 300 nutritionists, pharmacologists, gastroenterologists, ophthalmologists, pulmonary specialists, surgeons, nurses and dietitians and, for when the need aris- es, a pair of chaplains.

Under their care, he had grown to 18.1 in. (46 cm) and weighed 5 lb. 11.5 oz. (2,594 g), nourished by breast milk from his mother Melissa Hilger, 26, which was fed to him through a nasogastric tube thread- ed through his nose to his stomach. David’s father Kyle Joyce, 25, and Melissa live 90 minutes away in Randolph, Wis., where Kyle works as a diesel mechanic. They had been at the hospital every day after work for 51 days straight at that point—a three- hour round-trip—to spend a few more hours with David.

On that March morning, Merry Jay, David’s neonatal nurse, watched him until he stirred, then changed him and checked his monitor. His heart rate, respiration and blood-oxygen levels were good. Together, she and David waited for Katherine Fon- tier, a speech pathologist—which hardly sounds like a needed specialty in a NICU, but speech is all about the mouth, and to- day David was going to try to use his. Fon- tier arrived, checked the lighting (“When it’s too bright, preemies shut down,” she says) and gathered David into her arms, his lines trailing into his crib.

She dipped a pacifier into his mother’s milk and placed it in his mouth. His num- bers stayed steady. She replaced the paci- fier with a bottle filled with breast milk. David sucked, swallowing noisily. He squirmed, his heart rate and respiration dropped, and his blood-oxygen numbers flashed red. “He’s trying to coordinate sucking, swallowing and breathing,” Fontier said. She removed the bottle and gave him the pacifier. “O.K., O.K.,” she said softly. “Let’s go back to what he does well.” David got two more tries with the bottle that morning, then fell into an exhausted sleep. The feeding took 10 grueling min- utes. In that span, he drank 2 cc of milk. A teaspoon contains 5 cc.

There was a time when David would not have stood a chance. According to gov- ernment statistics, in 1960 the survival rate for infants under 1,500 g, or 3.3 lb., was 28%. In 2010 it was 78%, and a lot of that improvement has occurred just since the 1980s. The survival for any one baby is dictated first by the calendar. Come into the world at 22 weeks and you have only a 5% chance of making it out of the hos- pital alive. The odds improve to 26% at 23 weeks, 56% at 24 weeks, 76% at 25 weeks and up into the high 90s at 32 weeks and beyond. Even then, the battle’s not won, since the longer a baby remains in the womb, the fewer health problems there will be later. Still, survival is the first goal.

“Every decade since the 1960s, the age of viability has been reduced by a week,” says Dr. Edward McCabe, medical director of the March of Dimes Foundation.

This kind of progress inevitably raises tough questions. If you can keep a 22-weeker alive, what about 21 weeks, 20 weeks? How low is it fair to go if survival means a life- time of prematurity-related disabilities? Seventeen percent to 48% of preterm babies, for example, will have some kind of neu- romotor abnormality, including cerebral palsy. Cost is another issue. The March of Dimes calculates that babies born before 32 weeks’ gestation run up an average hospital bill of $280,811. Other estimates are lower, but either way, preemie care isn’t cheap. How much of a burden on a family—and suffering by a baby—makes sense?

Fortunately, for most preemies things are not this dire. Thanks to advances that had not been made even a few years ago, the odds of surviving and thriving are improving all the time. Lives that once might have begun and ended in a NICU can now be lived long and well—and there are many reasons that’s true.

Medical Mission Control

The biggest change in the care of preemies occurred very recently—in the past two years, in fact. For a long time, the most sophisticated of the newborn facili- ties was known as a Level III NICU, which was supposed to be equipped with all of the surgical capabilities and subspecialists needed to handle the tiniest and sickest ba- bies. But there was no consistent policing of the standards for a Level III designa- tion, so survival could be a geographical crapshoot. A preemie born within an ambulance ride of a good Level III would have a better chance of surviving than a same-size baby born elsewhere.

In 2012 the American Academy of Pedi- atrics decided to set that right, calling for the formalization of the standards applied to all three levels as well as the creation of a new Level IV designation for NICUs that not only have the staff and ORs to handle the toughest cases but are centrally lo- cated and can gather in families from the largest geographical footprint possible.

Competitive hospitals acted fast, and many have already made the changes necessary to earn a Level IV certification from their state hospital boards. The na- tional numbers are still very murky, and for a lot of reasons: the states don’t all talk to one another, no single body serves as a clearinghouse for Level IVs, and some states are still working from the old desig- nation of Level IIIc, which might be a IV in a different jurisdiction. However, the trend is promising, especially in big cities. Den- ver, Seattle, New York, Chicago, Atlanta, St. Louis, Philadelphia, Dallas, Boston and others have all cut ribbons on Level IVs, and many cities have more than one.

“There is so much that can go wrong with these babies so fast,” says Dr. Michael Uhing of the Milwaukee Level IV that was home to David. “You don’t have any choice but to come at the problem with as big a team and as many options as possible.”

Uhing’s NICU is among the best of the new breed, with a 97.5% discharge rate for preemies in the 2.8-to-3.3-lb. range (1,251 to 1,500 g) and a patient population that comes from across Wisconsin and four surrounding states. Kyle Joyce and Me- lissa Hilger are typical of the parents of those babies, living in a community that has a perfectly fine hospital but not one with a Level IV facility—and suddenly needing one. “We had just finished paint- ing David’s room, and the next day I was in the [local] ER,” Melissa says. “The room is still a work in progress.”

The ER led to the Milwaukee NICU, and Kyle and Melissa had to get used to the fact that it was a place they were going to come to know well. The average pree- mie is not released to go home until what would have been the 37th week of gesta- tion, which meant months for a 29-weeker like David. (He was actually released on April 17, one day past his 40-week, full- term due date.) Making things worse, from the moment parents arrive, the ba- by’s care is taken out of their hands. For the mother, nursing and pumping milk help some—it’s the one thing that only she can do. For the father, excluded from that loop, things are harder. “I’m a mechanic,” says Kyle. “I’m supposed to be able to fix anything. But I can’t fix this.”

The three-shift, 24-hour workday in the Milwaukee NICU begins with a morn- ing meeting dubbed “the huddle,” during which Uhing and the team gather to review the status of each baby. There is a quick, round-the-horn quality to the gathering, and that is by design. “The huddle is con- ducted standing up,” says Sarah Currie, a nurse and patient-care manager. “It gets the doctors to the babies as quickly as possible.”

What awaits them changes every day. On the morning David struggled to drink his milk, Uhing and his team met a newly arrived family. Around the 27-week-old baby’s incubator-like isolette, the lights were dimmer, the thicket of poles, drips and monitors denser. The little girl was born with a contraction of the limbs caused by moving too little in the womb, which can be linked to a neurological anomaly, though no one could know for sure until she was stable enough for a brain scan.

Even as this visit was under way, word came that another pretermer—a boy— was being born in the hospital. By the af- ternoon, the baby had arrived in the NICU, and it was clear that there was not just the possibility of neurological anomaly; there was grave brain damage from which recov- ery was unlikely. The mortal calculus is always relative in the NICU. Almost every set of parents can look around and find a family they envy and a family they ache for. The only families no one wants to be are the ones whose babies are never going home.

The team’s visit to David’s crib was happier, not least because of the very fact that it was a crib. “We don’t want our pree­ mies burning calories to stay warm,” says Currie, “so we keep them in an isolette to balance their temperature until they’ve put on weight. David graduated to a crib a couple weeks ago.”

Uhing reviewed David’s growth chart, and it looked steady, but he reminded the residents that growth isn’t everything. “We used to try to send home chubby kids,” he says. “Now we like them lean and mean. If the only goal is getting calories into them, we may set them up for obesity later.”

The Care Cascade

The mere fact that something can go wrong with as straight­up a treatment as getting food into a baby who badly needs it only hints at the complex, interlock­ing problems that preemie care involves. When it comes to the digestive system, overfeeding is just one complication. A preemie’s gut is not yet fully up to digest­ ing anything, including breast milk, and the combination of inflammation, bacte­ ria and low oxygen levels can cause infec­ tion; that, in turn, may lead to necrotizing enterocolitis, or tissue death in the intes­ tine. What determines which babies will develop the disorder is a mystery, how­ ever. “Some sail through, while others have problems,” says Dr. Ganesh Konduri, a Milwaukee neonatologist. “But they all look the same when they come in.”

Milk and medications can work against each other too. Preemies are administered medicine in vanishingly tiny doses—little more than the residue that would be left in a syringe or IV line after an adult dose is given. The only way to make sure all the medicine is taken is to mix it with some carrier fluid. But the fluid may dilute the effect of hard­won feedings, and every drug has a different chemical interaction with milk. For that reason, there is a constant negotiation between pharma­ cists and dietitians during the morning huddles and the weekly staff meetings at which every case on the ward is reviewed.

“I have to stay on good terms with the pharmacists,” says dietitian Elizabeth Polzin. “I say what I want, and they tell me if it’s safe. ‘If you want more protein, you’ll have to cut down on something else.’ ”

Getting preemies to breathe is far more complex, with far more danger of down­ stream effects. Preemie lungs lack mature air sacs—or alveoli—in which the ex­ change of oxygen for carbon dioxide takes place, as well as the production of a sub­ stance known as surfactant, which pre­ vents the lungs from collapsing and helps them absorb air and reject water. Artificial surfactant, administered into the trachea, was approved in 1990 and by 2002 had re­ duced deaths from respiratory distress in babies fifteenfold. That plus respirators, cannulas (nasal prongs that steadily feed a baby air) and the use of constant passive airway pressure (CPAP)—similar to the masks adults with sleep apnea wear— usually allow babies to absorb enough oxygen. David wore a CPAP for the first 17 days of his life, which was hard for the family. “It was such a high moment when he got rid of it,” says Kyle. “We could see his face for the first time.”

Even for good breathers, oxygen comes at a price. The highly reactive oxygen ions known as free radicals can scour lung tissue that’s already under siege. In the wrong quantities, oxygen can also lead to excessive blood­vessel growth in the eyes, damaging the retina and leading to what’s known as retinopathy of prematurity (ROP). It’s ROP that cost Stevie Wonder, born prematurely in 1950, his sight. “It’s amazing that we’ve been doing neonatol­ ogy for so long and still don’t know what the oxygen level should be,” says Uhing.

The least predictable consequence of treatment involves the preemie brain. Even a quiet NICU is a too cold, too bright assault, and much of the bustle is uncom­ fortable or painful. A 25­week­old baby is not meant to have a tube down its throat, a needle in its arm and monitors taped to its skin. Every one of those sensory insults takes a toll. “The brain doesn’t develop the way it should,” says Konduri. “MRIs show significant differences between a full- term baby and a 40-week baby who was born prematurely.”

Fixing the Problems

While the 37-week guideline is the broad rule for how long any one preemie will remain in the NICU, innovative treat- ments are being developed to get all pree- mies home sooner and stronger. One of the most powerful—and newly appreciated— therapies is as old as the human species: just plain holding babies as much as pos- sible, a technique called kangaroo care.

It’s no accident that infants are hard- wired to need cuddling and adults are hardwired to love to oblige. Respiration, heart rate, sleep cycles, appetite and more stabilize when a baby is in an adult’s arms. Oxytocin—the hormone often called the cuddle chemical—rises in both the cud- dlee and the cuddler. And when that cuddler is the mother, the extra oxyto- cin finds its way into breast milk, which doubles down on the dose the baby gets.

A newly released Israeli study followed a group of NICU babies born in the late 1990s, some of whom got kangaroo care and others who did not. At that time, the technique was not considered standard treatment and hospitals didn’t provide it on a systematic basis—at least not one that went beyond the amount of holding the babies received when relatives came to visit or they were otherwise being tended to. During exams at 3, 6, 12 and 24 months as well as at 5 and 10 years, the children who got constant cuddling outperformed the other group, with stabler sleep pat- terns, steadier respiration and heart rates and better attention skills.

For all that, even a preemie’s mother may find holding her baby surprisingly difficult, something Shannon Dreier, a Milwaukee mom whose son Abram was born at 26 weeks of gestation, discovered. “I was afraid to touch Abe,” she says. “The nurses are used to these babies. They’d say, ‘Get your hands in there.’ But it wasn’t un- til about a week after he was born that I was able to do kangaroo care.”

Another new treatment, far more exper- imental, involves the use of inhaled nitric oxide to increase blood flow to the lungs and improve function. The molecule— which is different from nitrous oxide, or laughing gas—is a vasodilator and is what helps give erectile-dysfunction drugs the

power to do what they do. For now, nitric oxide is delivered to preemies as a gas in low concentrations—about 10 parts per million—and is used only in babies who badly need it, because while it may benefit the lungs, its effect on other organs is less certain. Harry Ischiropoulos, a biochem- ist at the Children’s Hospital of Philadel- phia (CHOP), home to a celebrated regional NICU that is known for its research wing, is conducting studies to determine the im- pact of nitric oxide on brain metabolism, neurotransmission and responses to in- flammation. “Nitric oxide may give a boost to neurotransmitters,” Ischiropoulos says. “That could benefit the brain as a whole.”

Investigators are also looking into ways to bolster the preemie’s immune system in hope of reducing infections and inflam- matory diseases, particularly colitis. One way could be probiotics. A premature baby can be overwhelmed by some pathogens it finds in the outside world. But strategic dosings with beneficial bacteria may help the immune system switch itself on and get itself moving. “We could make a cock- tail to administer to babies to rebuild the gut in the right way,” says Dr. Scott Worth- en, a CHOP physician and investigator.

Other research involves pinpointing genes in the mother that may contribute to premature birth as well as those in babies that determine who will suffer complica- tions and who won’t. Ophthalmologists at CHOP are investigating drugs to inhibit abnormal blood-vessel growth in the eye and prevent loss of vision. Currently, laser surgery can control the problem, but it’s more invasive and often not an option at all in the developing world. “Kids are go- ing blind, and we know what to do about it, but we don’t have the resources,” says ophthalmologist Graham Quinn.

Endgame

Surviving babyhood is only part of the struggle. Premature babies have a life- long higher risk for a whole range of prob- lems. The odds of intellectual disability among preemies increases anywhere from 1.4-fold to 22-fold, depending on gestation- al age and birth weight. Stanford Univer- sity researchers recently found that people born prematurely stand a 38% greater risk of dying in young adulthood than full- termers, typically from heart problems, though the absolute numbers—fewer than 1 in 1,000 deaths—put that danger in perspective. University of Rhode Island studies found a 32% greater risk of asthma and vision problems. Overall, about 66% of preemies born before 27 weeks have some kind of disability at age 3, and many never fully recover.

Some, of course, don’t even get that far. Nearly all the progress in survival rates in the past 30 years has come from improving the outlook for babies born past 23 weeks. Below that, the numbers have barely budged. “You get to the point that the lungs are so immature, you’d need entirely different treatments,” says Uhing. “The skin is like a burn patient’s. It just falls off.”

The job in these cases is much more straightforward: to keep the baby com- fortable and prepare the family for what is to come. Milwaukee teaches nurses how to make plaster foot molds of the ba- bies while they’re still alive. Those keep- sakes are added to a memory box that includes the baby’s first—and sometimes only—swaddling blanket and T-shirt, as well as a family photo. And while babies in intensive care are kept in as isolated and germ-free an environment as pos- sible, when the game is lost and everyone knows it, the rules are waived.

“Some parents want to take the baby outside to see the stars or feel the sun at least once,” says Currie. “The lifesaving piece no longer applies.”

More and more, however, the life is saved, the baby does come home, and there are plenty of sunny days and starry nights ahead. In some ways, the work of a NICU will always seem like an exercise in disproportion—an army of people and a mountain of infrastructure caring for a pound of life. But it’s a disproportion that speaks very well of us. The babies, increasingly, are reaping the benefits.

Brand-New Day

In the global fight against AIDS, South Africa is making extraordinary strides in reducing mother-to-child transmission. Now a philanthropic initiative called Born Free is teaming up with the fashion industry to lend a hand.

“For the first time, we have things we can do that we know will work. The issue is, how do you scale it up so that you can talk about an AIDS-free generation?”
On the road
Victoria Beckham, in her own clothing, with children from the Imizamo Yethu township in Hout Bay, beside a Tutu Tester mobile HIV clinic. She is one of 23 designers – all mothers – collaborating on the Born Free Collection.
Together now
Kebede, next to Imizamo Yethu resident Yolanda Baliso and her family.
Sing out
The Sizophila Choir, run by the Desmond Tutu HIV Centre, helps support mothers and children with HIV.
Table talk
“Obviously I am a woman and a mother, and this issue touched me,” says Victoria Beckham.
Maternal instincts
Kebede, photographed with five mothers with HIV and their HIV-negative children in a local home in Khayelitsha.

Starting a Business? Here’s Your To-DO List

Emi Gal, serial entrepreneur and CEO of Brainient – a company that helps brands such as Channel 4 and FOX create interactive video advertising – shares his start-up checklist.

MAKE/OFFER GOODS OR SERVICES PEOPLE WANT
It’s a competitive global market; invest your time researching it. Only build something you know people will buy. Know your customers – and your competitors – by getting out there and meeting them.

ALWAYS ASK FOR FEEDBACK
When you’re building your business, it is incredibly important to test your product. Use your friends, family, network and potential customers for feedback from the start. This will save you bigger problems down the line.

BUILD YOUR TEAM WISELY
Recruitment is hard and it takes time. In a start-up, your first few hires are crucial for your business. Invest your time wisely – hire people you feel you can have a beer with and who will be as passionate about your start-up as you are.

DON’T FRET ABOUT YOUR LOCATION
At Brainient, we are headquartered in London, have a technology team in Romania, investors from the UK and Silicon Valley, and clients as far away as India. It doesn’t really matter where everyone is based, the internet has enabled all companies to go global.

LISTEN AND BE PATIENT
People with plenty of patience are wiser because they take the time to listen. As a founder, you need to learn this sooner rather than later. Some things can only be learnt from experience but the more you listen, the quicker you will learn.

BE AMBITIOUS, BUT PLAN
Great ambition is the passion of a great character. Investors will respect you for aiming high, but back it up with a thorough road map of how you plan to get there. Think about how you will scale, and make a five-year plan not a one-year.

CONSIDER AN ACCELERATOR
There are a host of accelerators out there to consider if you want to kick start your business and open yourself to a new network of opportunity. Do your research to find the best accelerator program for you. The benefits are numerous; credibility, validation, focus and momentum to name a few.

HAVE FUN!
Fun is a great motivator. Walk into work with a smile and chances are you’ll be more productive. Lead your team by example and have fun every day!

Secret Diary of an Entrepreneur

Lexi Tamasan, founder of PetShopBowl.co.uk, reveals a typical week running her pet retail business.

Lexi Tamasan and her partner, Adam Taylor founded their company, PetShopBowl.co.uk, in 2010 with a £5,000 grant from The Prince’s Trust. Now PetShopBowl.co.uk is the UK’s leading online pet retailer with a multi million-pound turnover.

DAY ONE: ENGAGING WITH PET PARENTS
When we first started PetShopBowl.co.uk, the retail side of the business was very capital-intensive and took up a lot of our funds. This meant that social media became one of our key ways to engage with our pet parents. Since then it has become a mainstay in our marketing campaign. Every Monday, I spend a considerable time overviewing the week’s social media activity and looking at the content we need to create to engage with our core audience. This includes any upcoming special occasions or dates, stories in the news that we can react to, as well as making sure that we inform customers about current or upcoming offers. A key part of our philosophy at PetShopBowl.co.uk is to know and engage with our individual customers. Facebook has proven to be a great way for us to do this. For example, a few months ago, a customer’s dog sadly passed away, and we posted a message about it. This received more than 1,000 likes and somebody even wrote a poem for the mourning pet parent.

DAY TWO: THE WAREHOUSE
Last year, I decided to cancel my gym membership. I get my workout from lifting and packing boxes in the warehouse. And that’s how I spend most of this morning. More people than expected have taken advantage of our sale on our repeat subscription service; Bottomless Bowl. It allows them to automatically receive repeat food deliveries every few weeks. The frequency is set by the customer, so we’ve been driving forklift trucks and packing items to get them out. Last year, we decided that we were going to launch an app. The intention was that pet parents would be able to order food wherever and whenever they wanted. As a result, I’ve been on the phone to app developers from across the globe trying to find the best partner for us to work with. I spend several hours in the afternoon finalising the right person for the job, and then running through the brief with them.

DAY THREE: MARKETING AND CSR
After some heavy rain last night, Adam (co-founder) and I are in early to check that there was no damage to the warehouse or any of the products. Just when we thought that we were safe, we discover a number of dry dog food bags that have split and therefore can’t be sold. Unrelated to the rain. Luckily, after some posts on Facebook, we manage to donate the bags to the team at the UK German Shepherd Rescue Centre. It’s a good feeling being able to give unsaleable food to a good home – there were twenty big bags there, and ultimately they would just have to be binned. Even though I can drive a forklift truck and pack with the best of them, my real forte is marketing, and so I am quite relieved when my Outlook diary reminded me about a conference call with our PR agency. Unfortunately, that’s all top secret so I can’t talk about it too much, but there’s an exciting launch on the way. Watch this space! The rest of the day is spent on making sure our packing design is in line with our brand identity and philosophy. All outgoing packages now have a joke on the bottom, and include details about our Facebook, encouraging pet parents to post photos of their pets with our branded boxes.

DAY FOUR: ADMIN
This is the one day of the week that I think all entrepreneurs will identify with. Bookkeeping. It’s not fun. It’s not glamorous, but it’s the heart and soul of any business and needs to be regularly kept up to date. Luckily, I get to break it up with a few interviews for three graduate positions to assist on key accounts.

DAY FIVE: E-COMMERCE
PetShopBowl.co.uk is a friendly, family-run business and it’s important to remember that above all else, we are an e-tailer. It’s important that we make it as easy as possible for consumers to purchase from us. So whilst our app is in development, we need to make sure our mobile site is fully optimised to allow consumers to purchase products easily and securely across both iPhone and Android systems. As a result, my morning was spent looking at the back office for PetShopBowl.co.uk and making sure that the full website experience translates across to the mobile version. For customers to be able to order these items though, we first need to order them from Mars and Nestle. So, I spent most of my afternoon forecasting what foods and accessories we will need and when they arrive at PetShopBowl.co.uk HQ. This ensures that there is always a strong flow of products through our warehouse. Important, as food products are obviously perishable.