[1997] For four years (1993-97), I worked with a neonatologist at the University of Miami School of Medicine. My work with her – which included three days onsite in Miami each month -- began during my Vermont years when a mutual friend recommended me to her and extended through my years in New Orleans with the LSU Ob/Gyn Department.
“Dr. Brown, I am losing the vision. I am stumbling as a leader. My staff is floundering. I am exhausted. What can you say or do that would matter?”
Just a few minutes into this April 1993 conversation – our first – my new physician friend made it clear she was far beneath the heroic glitter often associated with high-achieving academic physicians. This no-nonsense neonatologist had neither time for nor interest in softing platitudes about medicine. She knew better and intended to determine quickly if I did. The look in her eyes said, “Think twice before answering.”
Working with this neonatologist and her staff over the next several years shook my foundations – in the heart as much as in the mind. For the first time, championing individuals trapped and desperate in oppressive circumstances carried for me a real element of personal danger. The target population – cocaine-abusing women living in a violent part of Miami who were prematurely delivering cocaine-exposed babies.
- Individual Factors. These women and their children were at serious risk to undervalue education, to see women treated as inferior to men, to absorb the language and assumptions of racial prejudice, to underutilize primary healthcare services, to lack proper nourishment, to thirst for genuine attention, to cease to dream. Childlike resiliency, concreteness, and a sense of humor insulated them somewhat from the full impact of their circumstances.
- Family Factors. These women and their children were at serious risk to carry parenting responsibilities for younger siblings, to suffer physical and/or psychological abuse, to witness/experience domestic violence, to not know one or both parents, to lack family support for educational achievement, to never have celebrated a birthday, to feel betrayed, to regard adolescent pregnancy as normal. The incidence of adolescent pregnancy could, ironically, be reinforced by family members (whose behavior toward the pregnant girl often became dramatically more gentle and affirming) and by the expanded availability of societal resources. Many of these women desperately wanted to retain parental responsibility for their children. Few, if any, wanted their children to experience their way of life. Extended family members (esp., grandmothers) often shielded their children from at least the most severe disadvantages and conveyed to them that they were loved and wanted.
- Education Factors. These women and their children were at serious risk to have attended school irregularly, to have been taught by demoralized teachers, to have attended improperly equipped schools, to have formed poor study habits, to have had discipline problems, to have lost their intellectual curiosity.
- Peer Factors. These women and their children were at serious risk to form relationships based on ‘macho’, to link self-image to strength, to resort quickly to violence when in conflicts, to be taunted toward destructive misbehavior, to be suspicious of others, to find street-gangs attractive. Community-based athletic programs, religious organizations, substance-abuse support groups (e.g., TRUST Groups), and community-based social organizations (e.g., Big Brother/Sister, YMCA/YWCA, Boys/Girls Club) made constructive peer relationships at least a possibility.
- Neighborhood Factors. These women and their children were at serious risk to lack a sense of pride in their community, to live in deteriorated housing, to change residence frequently, to regard violence as normal, to have a street name, to ‘work’ on a lower rung of the drug-world ladder, to have a family member and/or neighbor who had died a violent death or who had AIDS, to regard the police as the enemy. Their neighborhoods did vary in the degree of risk they posed. Even in the most hostile neighborhoods, local groups -- some formally established, others ‘street-organized’ -- could be found working to insure a measure of safety and encouragement for these women and their children.
- Society/Media Factors. These women and their children were at serious risk to have no sense of membership in the larger society, to have never visited other parts of the city, to have learned by watching closely the adults around them how to ‘work the system’, to have a surreal worldview shaped by television, to be influenced by militant music, to place no value on newspapers or news magazines. Harsh predispositions against them -- widespread in the larger society -- made interactions across social lines predictably adversarial. Sustained efforts to introduce resources and options (e.g., businesses, vocational institutes, and community colleges) could be found attempting to create fresh start opportunities.
In that first conversation, my new physician friend spoke candidly about her struggle to launch the second of two multi-million dollar federal grants for which she was the principal investigator. Soon after beginning her academic year in the late 1980s, she had become alarmed by the incidence of babies being admitted to the neonatal intensive care unit at Jackson Hospital after testing positive at birth for cocaine exposure. When discharged, their mothers took them home to Liberty City or Overtown . . . inner-city wastelands on the northwestern edge of Miami that were plagued by violence, depressed by grinding poverty, organized around an illicit drug ‘industry’, threatened by devastating sexually transmitted disease epidemics.
Headlines from major cities across the country warned of frightening ‘crack baby’ scenarios. Scientific data were needed to test the escalating societal fears or to rein in the speculation. Her first federal grant allowed her to organize a research team to track the medical and psycho-social consequences of cocaine exposure for @300 babies through their first five years of life. Responses from her department chair and colleagues were supportive. The research would be clearly scientific. The subject matter was pediatric, if not neonatal. Her academic career would be enhanced.
A year later, she successfully added a second federal grant to fund a five-year intervention project designed to break into the personal and parental dysfunction of @120 cocaine-abusing mothers whose babies were compromised by premature birth as well as by cocaine-exposure during pregnancy. Responses from her department chair and colleagues chilled considerably. Little hard data would be generated. Few scientifically derived conclusions would result. They considered the subject matter public health, not medical; for social workers, not neonatologists. Her academic career would stall.
She pressed on. She had seen too much to turn back without sacrificing her integrity. She had access to these mothers at an emotionally receptive moment. She had an idea that just might work:
Premature birth put these babies at risk for more reasons than cocaine exposure. If we concentrate for five years on the interests of the babies, might the wary mothers notice the value we are placing on their children? Might we eventually break through their suspicion that we are yet one more hollow gesture from ‘the system’ with the intent to manipulate? Might they stay near enough for our example to strengthen in them the maternal instincts necessary to justify their keeping their children?
But moving this noble idea into reality proved rough. Shortly after the proposal was funded, two medical school collaborators abruptly abandoned her leadership team, pulling critical legs out from under the project. Then Hurricane Andrew slammed through Miami, leaving the city in utter chaos. Six months later, signs of recovery in the city were still scant. With the cocaine-abusing mothers scattered by the storm and difficult to locate, her turf battles with other researchers intensified. And her case management staff had completely turned over.
My first task was to help my new physician friend regroup. We went back to basics. Could she answer the five questions of a forceful/centering mission statement – i.e., Who/what are we? What do we do? For whom do we do what we do? To what end do we do what we do? Within/upon what values do we do what we do? Only then could she determine what (if any) goals were still feasible.
We tested her answers during a two-day retreat with the entire staff. In fact, their being a ‘staff’ was a crucial issue. Each one knew how to do just enough to stay employed. But their leader needed more. She needed them to be a staff analogous to the staffs used by the hikers on the Appalachian Trail I saw passing through our Vermont village each fall. Why did she need them to ‘buy into’ the project? Because the intervention could work only if we all shared a respect for the cocaine-abusing mothers that would protect us from keeping them at a safe distance, that would steer us away from prejudging them, that would challenge us not to leave them conveniently ‘boxed’.
We proposed to rebuild the intervention project around writing life narratives with/about the mothers. Each mother’s story was badly broken. But it was her story. And we were convinced there was more to each mother than her cocaine addiction. Piecing together these narratives meant being fully present with the mothers. The case managers and I had to risk going again and again to where the mothers lived – to ‘Dirt City’ under an I-95 overpass where homeless individuals and families lived in crates, to the women’s jail cells, to treatment centers, to public housing apartments flanked by drug runners and heavily-armed drug guards, to abandoned lots dotted with packing boxes for shelter, to elementary schools isolated by towering chain-linked security fences, to corner stores that fronted for drug deals, to cocaine dens, to . . . . In doing so, most of us had to clean out biases deep within ourselves – biases against the poor and against African-Americans -- that had never before been so disturbed or challenged.
The gamble -- that enlarging our hearts with respect for the mothers as survivors would trump burdening our hearts with insight into the layers of utter tragedy carried by the mothers. The gamble -- that a passionate vision would overcome crippling burn out. So we restarted the project. We all wrestled with defining success. We all questioned whether trying to keep these mothers and their children together was the right thing to do. We all cared.
