The Baby Factory

At Houston’s Jeff Davis Hospital, where more than 10,000 babies are born every year, charity, idealism, and bureaucracy confront the ancient instincts of the flesh.

January 1980By Comments

Rafael Villanueva opened his eyes upon a vast field of pink. The nurse who held him made a perfunctory soothing sound and shifted his slight weight to the crook of one arm, leaving her right hand free to change the liner on a baby scale. The infant squirmed and burrowed his head deeper into the nurse’s pink hospital gown. He was fourteen minutes old. There were still a few traces of blood on his face and his deep fetal creases were filled with the mucous coating of birth.

The nurse was a large black woman with auburn hair. Her movements were brisk, economical. She placed the baby on the scale, recorded his weight, then double-checked the data on the ID bracelets that had been placed around his wrist and ankle. When she was through she picked him up again and with her free hand unfastened the locks on the door of a nearby incubator. She laid the baby on his back in the incubator and then, with a distracted motion no more consequential than the closing of a suitcase, snapped the door shut again.

I watched the baby through the clear Plexiglas. He made slow backpedaling motions with his feet, the soles of which were still stained with ink from the footprints that had been taken immediately after birth. He made a strange mewling sound that seemed neither contented nor distressed but had a vague experimental timbre, as if he were gauging the acoustic properties of his new environment. He looked utterly isolated, but in this room—the Transitional Care Nursery, where healthy babies spend the first six hours of their lives—there were at least a dozen other newborns entertaining their simple reveries in the warm, womblike air of their incubators.

Rafael Villanueva was one of the 30 babies born this November day at Jefferson Davis Hospital in Houston, one of the country’s great wellsprings of human life. Like Ben Taub, it is a charity hospital run by Harris County, and its primary function these days is to provide the county’s indigent population with obstetrical care. Almost 14,000 babies were born here in 1979, more than at any other hospital in the United States except the Los Angeles County Women’s Hospital. They were born to the poor and displaced: to thirteen-year-old girls, to Vietnamese refugees, to Northern laborers who had come to the Sunbelt looking for work and had lost their medical insurance in the interim between jobs, to illegal aliens for whom giving birth at JD constituted a pro forma proof of citizenship.

For the average middle-class parent, accustomed to tending the garden of family life with such neurotic devotion, JD can be a frightening place. Certain elemental forces are more obviously at work there than in the stunning tranquility of an institution like the Woman’s Hospital of Texas across town on Fannin Street, where women in labor seem to regard childbirth as hardly more strenuous than a particularly challenging yoga exercise, where the hospital even provides a birthday cake for the new arrival. JD is raw, spare, chaotic; one who enters the county hospital is struck with an impression of having stumbled into the path of a raging natural force.

“The poor folks are really going to be lucky,” County Judge Roy Hofheinz said when Jefferson Davis Hospital was built in 1937. By and large his prediction was not quite borne out. For almost all of its history, JD has been a source of controversy, first as a financial hot potato handed off between the city and the county, then—as conditions there became more apparent to the general population—as a place of unrelieved suffering and bureaucratic apathy. It was chronically overcrowded, understaffed, and unsanitary, if not outright filthy. The situation reached a tragic climax in a staphylococcus outbreak that occurred in 1957 and was not contained until two years later, after 24 infants had died.

The creation of the Harris County Hospital District gave Jeff Davis a reliable, if generally inadequate, financial base, and the construction of Ben Taub in 1964 made possible the gradual conversion of JD into a hospital primarily for maternity cases. Even with such a limited focus, the facilities have frequently proved inadequate. Until the new maternity wing was built last August, women gave birth in a cramped, cheerless hospital addition that had originally been built as a polio ward. On the frequent occasions when the labor rooms were full, mothers were lined up in their beds on both sides of a narrow corridor, howling in pain and fear and pleading for the attention of the harried staff. At one point in 1975 there were so many unexpected births that newborn babies had to be kept in cardboard cribs that were taped together so a misplaced elbow or broom handle would not jostle an infant to the floor.

Conditions are much improved now that the new Winifred Wallace Maternity Center has been opened, though even there it is not uncommon for women in labor to be crowded out into the hallways. The place is pleasant and well lit, but it cannot compensate for the outright agonies of women who are often ignorant about the process of birth. If one stops and listens, what one hears most, beneath the canopy of Muzak, are groans and lonely pining sounds, and the occasional terrible, surprised bleating of a fifteen-year-old girl who doesn’t understand what is happening to her.

I wandered lost through the core of the hospital, trying to find my way to the labor and delivery section of the new maternity wing. The building was a patternless maze, with so many mismatched floors that I found it necessary to ride up or down in elevators just to stay level. It was lunchtime, and a sour, cabbagelike smell emanated from the staff cafeteria. A woman stood near a vending machine, eating with her fingers the contents of a can labeled “cocktail tamales.” The anonymous hallways were jammed with people of every race. Pregnant women, wearing T-shirts printed with the word “baby,” more often than not herded three or four children as they walked along looking for the maternity clinic. Teenage girls recuperating from the delivery of their babies padded down the corridors in fuzzy Day-Glo slippers or waited in line at the pay phones for a chance to plead with their boyfriends or to tell them how much they didn’t need them. In the maternity waiting room, known as “the stork club,” a group of people sat watching a big television with tin foil wrapped around the ends of its rabbit ears.

I walked past the pharmacy waiting room, which was full, and then past the casher’s office, where several people were undergoing “financial counseling” to determine how they would pay JD for its services. Hospital policy dictates that no one can be turned away in an emergency, but otherwise the admission requirements are rather stringent. The fact that JD is a charity hospital does not mean that patients are not expected to pay for the care they receive. Everyone who applies for admission is required to present proof of income, along with some sort of verification that he is a resident of Harris County. How much a patient pays is determined by a sliding scale that takes into account his income and number of dependents. “Overscale” patients are referred to other hospitals, and those who fall “within the code” are given a designation that indicates how much of the hospital fee they are expected to pay. An “A” patient pays nothing, while an “E,” at the other end of the scale, is liable for the entire amount, which for a routine delivery is usually $1200, about half of what it would cost for a private hospital and the services of a private obstetrician.

When I arrived at the maternity wing, a man was stamping about the nurses’ station in a state of barely contained fury. He was very short and compact, with a crew cut, thick black-framed glasses and a glossy black vest that he wore over a T-shirt.

“My wife had a baby at 3:04,” he told me. “It’s now eight o’clock and she still hasn’t seen the doctor. I’m trying to talk to the head nurse. I had her paged a half hour ago and she’s still not here. I’ll never come back here again. When they finally took my wife into the delivery room the baby’s head was showing completely.”

The two nurses on duty were whispering to one another behind their desk, trying to decide how to deal with him.

“Ma’am,” the man called when he saw them conspiring, “ma’am, if you’re going to call me a liar you can say it to my face!”

“I was not calling you a liar, sir,” the nurse said wearily.

Finally he was given permission to go back to the recovery room to see his wife. He put on a pink-striped gown—resentfully—and stormed off down the hall.

The other people at the nurses’ station were more accommodating. A boy of about sixteen mumbled, half-embarrassed, to the nurse, “I’m supposed to see my baby, you know. The one she had this morning.”

The nurse told the boy he had to get a pass and pointed him down the hall, past a set of swinging doors where a nurse stood gossiping with an armed security guard. In a few minutes the boy returned with a piece of paper and held it up to the window of the Transitional Care Nursery. The nurse inside looked at it, then walked around the nursery reading the labels on the incubators and scratching her head, as if the baby had been misplaced. Finally she located it and held it up. The father looked at his son. Not knowing how to react, he simply nodded. The nurse held the baby out and mouthed a question—“Do you want to hold him?” The father could not understand her, probably could not, in his mild form of shock, have conceived of such a thing anyway. Thinking that she was asking to see his pass again, he held it up to the window for her inspection.

The boy was fairly representative of the general mood of the patients and visitors. To them JD was an acceptable place, because they did not think to ask questions or make demands. They seemed to regard its existence as unquestioningly as they regarded the phenomenon of birth itself. The hospital was there, it seemed to function, to fulfill its purpose. There was little else to be said about it.

I more or less shared that impression. Obviously there were severe problems at JD, but they were the sort of problems—too many patients, too few staff members—that one expected to find in a county hospital serving an indigent population in a region of unprecedented growth.

JD’s budget for 1979 was $17 million. “With the increase in volume we’ve had,” Lois Moore, the hospital administrator, told me, “the budget has just not been adequate to meet the needs. We budgeted for eighty per cent occupancy last year, and our occupancy has been up for several months of this year to as high as a hundred and six and a hundred and seven percent.”

I walked down the hall to the labor rooms and made the rounds with a group of residents. There were six labor rooms, with a total of seventeen beds. The women lay back warily as the doctors approached them, gripping the bed rail as the contractions came. They seemed utterly alone, bewildered. From machines next to their beds came the steady deep-ocean pinging of their babies’ hearts.

The delivery rooms were father down the hall, behind a pair of double doors that burst theatrically open whenever an emergency delivery was wheeled through them. No one was admitted back there without putting on a set of scrubs and the paper shoes and hats that one pulled out of a box that was like a giant Kleenex dispenser.

Only two of the six delivery rooms were in use, which constituted a sort of lull. But already the work was beginning to stack up in the labor rooms, where four or five women were close to delivery and four candidates for Caesarean section lay waiting.

“Yeah, we’ve got a lot of sections tonight,” an obstetrics resident named Robert Zurawin told me as he scrubbed his hands with a disposable soap-and-brush combination called E-Z-Prep. He was friendly, slightly sardonic in the accepted manner of young doctors.

“Maybe it has to do with the phases of the moon. One night, for instance, you might get nothing but ladies who are bleeding from their placentas. I remember one night we had all the chapters of the obstetrical textbook come in one right after the other.

“We see a lot of CPDs,” Zurawin went on, referring to cephalopelvic disproportion, a condition in which the mother’s pelvis is too small to accommodate her baby’s head. “You get an unbelievable number of those in Vietnamese. What happens is you have these tiny little people who are starving in Viet Nam. They come over here and start eating well, and then the first thing you know we have American babies coming out of Vietnamese bodies.”

Zurawin was originally from New York, where he had occasionally acted in amateur productions, until he realized that the life of a doctor satisfied his theatrical instincts. Like all the other residents at JD, he was on the staff of the Baylor College of Medicine, which provides doctors on a contractual basis to most of the hospitals in Houston.

For the most part, the doctors are just passing through. JD is simply another place they work on their rotation schedule. For the nurses the situation is different: the hospital is their place of employment, and fewer and fewer nurses are willing to subject themselves to it on a career basis. It is not, by any standard short of martyrdom, a pleasant place to work. “It’s a pit,” a doctor told me. “It really is disgusting. You’re in piss and shit and blood all day. You don’t have that at Methodist.”

“It looks good to have it on your résumé,” was the reason one nurse gave for working at the hospital. “People will take you more seriously when you apply for a job at a nicer hospital—it’s considered good experience to have worked here.” The experience includes a tangible racial tension heightened by the stress involved in ministering to screaming mothers, placating outraged relatives, and trying to communicate with departmental fiefdoms that are sometimes run with an obsessive devotion to protocol.

“At JD,” Lois Moore told me, “we’ve tried to remain competitive with the salaries nurses get in the Medical Center, and we have. We have ten holidays a year, excellent insurance, a fully paid pension plan. The benefits are good, the salaries are good, but when you add the stress that you have here you just get fewer takers. Maybe we could raise the salaries to such a level that they would provide a real incentive for people to work here, but we’re a tax-supported institution, and who are we to pay these high salaries when they’re not getting that in the private sector?”

A woman walked by pushing a used obstetrical tray littered with bloodstained instruments and swabs and a stainless-steel container, about the size of a cereal bowl, that held a placenta. It looked like a piece of meat someone had left out to marinate.

The lull continued for a while, then the double doors banged open and a woman was wheeled into the hall.

“I’ve got to do a forceps on her,” the doctor who was with her announced. “Her FHT has dropped to about eighty. She’s also meconium.”

What all that meant was that the fetal heart monitor had detected a sudden drop in the rate of the baby’s heartbeat. The baby had also had a bowl movement in the womb, excreting a dark greenish substance called meconium. If he drew it into his lungs with his first few breaths, it could cause pneumonia.

Seven people, including a pediatrics nurse from the Neonatal Intensive Care Unit across the hall, crowded around the mother in the delivery room. They put her feet in the stirrups and draped her body with blue surgical paper. The woman was screaming desperately, awash in the pain of childbirth. One of the doctors—an intern—began to probe with the forceps. I was surprised at what a tenacious, prying motion he used. The intern worked the forceps back and forth like a gardener trying to dig up a stubborn root.

The mother lay with her head turned to the side. “Oh God, oh God, oh Gaaawwwwed,” she shouted, panting for breath at the same time. The intern worked over her, diligently and dispassionately. It was a strange tableau of finesse and brutal pain, of abandon and precision.

The nurse from ICU stood by with a towel, ready to receive the baby before it took its first breath. She stood poised on the balls of her feet, flexing her knees. When the baby came, the doctor pulled it free like a quarterback taking a snap and handed it off to the nurse, who took off running. She tore through the swinging doors that led to ICU and placed the baby in a crib that was part of a tall bank of instruments and monitors. She inserted a clear plastic tube down its nose and, using her lips, siphoned the meconium out of its lungs.

“Life is the pits, isn’t it, honey?” she said to the baby as she withdrew the tube. They were the first words ever spoken to him. The baby calmed a bit as the nurse checked his other vital signs—his crying modulated from a high, distressed gasping to a sound that was like the baa of a lamb. As I watched, the baby’s skin changed in color from the bloodless gray of the womb to a healthy pink.

I wandered back out into the delivery corridor in time to see Zurawin beginning a Caesarean section on a girl who looked no older than fourteen but who, I learned later, was eighteen and delivering her second child. I watched through a large window in the hall as Zurawin muttered some words of comfort to the girl before the anesthesiologist put her under. While he waited for the anesthetic to take full effect, he stood over her, doing the twist and twirling his scalpel over the prepped yellow summit of her abdomen. He was two-thirds of the way through his 36-hour shift and seemed to be settling into a sustaining manic pace. When the time came to touch the surgical steel to the girl’s skin he began to recall all the random energy he had been throwing out; in an instant he was focused, concentrated.

The incision was deep and swift—from out in the hall I could hear the sound of the scalpel as it cut through the girl’s flesh—and there was an immediate welling-up of blood, enhanced by the sharp surgical lights overhead. I could not believe how simple it was. Zurawin opened up the patient’s stomach like a valise, looked inside, then reached in with both hands and lifted out a baby girl, covered in blood, taken absolutely by surprise. The baby looked alarmed and betrayed. She was small, less than five pounds, and so a nurse took her over to ICU.

“You got gypped on the groceries, didn’t you?” the nurse said to the baby as she walked down the hall.

Zurawin and his team kept working on the woman. They performed a tubal ligation that she had requested and removed her appendix. From time to time Zurawin lifted out blood-soaked sponges from her body cavity, which the nurse who was assisting him tossed onto a piece of blue paper spread out on the floor.

All the delivery rooms were now in use. I could turn in a circle and glimpse, almost simultaneously, the births of four or five babies. Every half hour or so one of the women would be wheeled down to recovery, the room would be mopped and cleaned, and then another woman would be propelled through the doors on her bed, propped up on her elbows, her face contorted in pain, while the doctor or nurse running beside her yelled, “Don’t push! Don’t push!”

“Hey, Jim,” one of the residents called to another down the hall. “Wanna assist? Girl down here about to crown.”

“Okay,” he answered wearily, “but I’m not going to scrub until I see the whites of his eyes.”

The babies made their entrance into the world with a twisting, spiraling motion, muscling through the vaginal constriction and delivering themselves into the hands of the obstetricians, who checked them over, showed them without a great deal of fuss to the mothers, and handed them to a nurse who put them in a nearby warmer, cleaned them off, and took their footprints. The babies shrieked and flailed their arms. They seemed to deserve some kind of explanation. Once I saw a nurse walk into the delivery room and toss a hospital form into the warmer, where it landed on a baby’s head. No one bothered to remove it.

But there was room on the assembly line for moments of calm, of conventional joy. In one room a Mexican American woman gave birth in a forthright, timeless manner, letting out one small shriek and then settling back, panting and blowing in accordance with the precepts of natural childbirth. When the baby came, the young, bearded doctor held it for her to see. She lifted her head off the table, moved her lips in reply to something the doctor had said, then lay back down, looking dreamily through the window out into the hall.

At about one in the morning things began to quiet down again. I went with Zurawin to one of the labor rooms, where he conducted an ultrasound scan of a woman who had come into the observation ward fearing that she had had a miscarriage. She was a white woman of about thirty. When Zurawin attached the sensors to her abdomen, she watched the electronic image that appeared on the screen. It was like a transmission from another planet, the dark night sky of amniotic fluid, the rolling terrain that made up, to a practiced eye, the form of a human fetus.

“Well,” Zurawin said, turning off the machine and leaning over the woman’s bed, “I can’t find a heartbeat.”

The woman nodded, as if in professional agreement. He held out some hope that another scanner might pick up a heartbeat where this one had failed.

“So I think the best thing is to get you admitted tonight and have you checked out in the morning. Then we’ll decide what to do from there. Okay?”

“Okay,” she said.

“Okay,” Zurawin said again, softly.

“The baby’s dead,” he told me back in the doctor’s lounge. “She knows it too. She just doesn’t want to admit it yet. Besides, there’s always a chance the other machine will pick up something.”

He opened a refrigerator. It was full of packages of cheese and potato chips and some moldy fruit. He put a piece of lunch meat into a microwave.

“Yeah, it’s a rush. It’s a real rush,” he mused as he waited for the meat to heat up. When it was ready, he took it out of the microwave, tossed it around in his fingers until it had cooled down a little, and then ate it by itself.

“It can be very sad here sometimes,” he said. “Especially if you want to talk about the social aspects. You look at those new babies and they’re soft and warm and cuddly, and then you pick up the chart and see that the mother is fifteen years old, unmarried, and has three other kids. You ask yourself what kind of life that baby’s going to have. You know, I have this fantasy sometimes of being thirty-five or forty and walking into a Seven-Eleven. Here’s this kid I delivered holding the place up. He turns his shotgun around and just blows me away.”

Teenage pregnancy is the single greatest problem that Jefferson Davis Hospital faces. In 1978 over four thousand girls under the age of nineteen, the great majority of them unmarried, gave birth at JD. Two of these girls were twelve years old.

Teenage pregnancy is epidemic in every segment of American society, and its discovery as a white middle-class phenomenon corresponds with its recent status as a political issue. The sharp rise in teenage pregnancy is blamed on a variety of causes—the statistically earlier maturation of young bodies, meager and sporadic sex education that has not kept pace with sexual opportunities, teenage unemployment, or just a simple, unrealistic desire to have a baby.

Pregnant teenagers, as a group, constitute a high-risk category. They are more prone than the general population to pregnancy-related conditions like eclampsia and toxemia; because their nutrition is frequently so poor, they have less tolerance for the rigors of delivery and may recover less quickly; and being teenagers, they are apt to be generally bewildered.

“Some of these girls,” said Audrine Scales, the adult development coordinator on JD’s fifth floor, which is set aside for teenage mothers, “perceive babies as dolls. They’ve been taking care of their younger brothers and sisters at home and think that having their own baby won’t be any more complicated than that. The majority of them keep their babies—they want their babies. Some of these pregnancies are planned. I know that sounds a little strange, but it’s true.”

Scales’ office was filled with literature, in English and Spanish, explaining to teenage girls the importance of nutrition, of birth control, of personal hygiene. Teenagers at JD are bombarded with such services—antepartum and postpartum classes in maternity care and birth control are conducted twice daily by the Goldfarb Adult Development Clinic, a program of the Baylor College of Medicine; the Houston Independent School District holds classes for high school girls in a group of temporary buildings in the hospital parking lot; the Texas Department of Human Resources has assigned a special child welfare caseworker to the hospital.

I went with Peggy Smith, the director of the Goldfarb program, to visit two seventeen-year-old girls who had delivered several days earlier and were scheduled to be discharged that afternoon. Their names were Stephanie and Wanda. Both of them had given birth to boys who were now in the Low Risk Nursery, though no one had told the mothers what was wrong with their babies.

I asked Stephanie what she thought about the hospital. She smiled sarcastically and looked out the window.

“There’s nothin’ to do here,” she said. “There no television, no phone. The food be cold all the time.”

Wanda sat on her bed and stayed out of the conversation.

“My little baby looks so sad,” Stephanie said. “Someone’s got his eyes all covered up. How about when they sit there and cry and no one will do nothin’ for ‘em? It makes me sad. I guess they just have to estimate what they’re crying for.”

Smith explained that a baby cries different ways when he wants different things, and that the nurses were trained to recognize those different kinds of cries and respond to them.

“Their hair be dirty too,” Stephanie added.

“Well,” Smith said, “they have on their heads something called vernix caseosa. Mother Nature protects the head with this. It’s a cheesy substance, it’s not real pretty, but it’s not medically significant.”

Stephanie nodded, eager for any sort of explanation. She was doing her best. She said she was going back to secretarial school, that her mother would take care of the baby while she was in class. I asked her about the baby’s father.

“I don’t want to see him ever,” she said. “But he stays right behind me.”

At two o’clock that afternoon a group of teenage mothers began gathering in a sitting room on the fifth floor. There were a dozen of them, wearing robes and paper shoes, smoking cigarettes as they waited for their lecture on birth control to begin. One or two of them spoke to each other—“What’d you have?” “Boy”—but for the most part they were silent, patient.

A middle-aged woman in a blue knit suit came in, carrying a little utility case and a plastic model of a uterus. She set the model down on the table, then opened the case and began taking out birth control pills, condoms, diaphragms, IUDs, and various foams and gels. When it was all set up to her satisfaction, she rubbed her hands together and introduced herself.

“Okay,” she said. “I’m Mrs. Peak. I’m from the city health department, and my duty today is to tell you about the various methods of birth control.”

Mrs. Peak spoke in a straightforward fashion, giving an impression of having unconsciously memorized and rehearsed her talk. She began by telling the girls about their neighborhood clinics, about the importance of having their babies vaccinated and of maintaining a shot record, about the hazards of becoming pregnant after the age of 35.

She showed them an anatomical chart of the vagina and the uterus, and warned them to keep their episiotomy incisions free from infection.

“There’s a culprit down below here,” she said, pointing with her ball-point pen to the chart, “which is your anus, or rectum. Everything in the barnyard is down there, and it can come up and infect your suture line.”

The nurse went on to talk about menstruation, which she said was “the weeping of a disappointed uterus,” and then began demonstrating the contraceptive devices, showing the girls how to load birth control pills into their little plastic dispensers. She held up a condom, identified it as “the oldest form of birth control known to man,” and had the girls pass it around. They handed it off to one another without looking at it as the nurse moved on to discuss the care of diaphragms.

“Wash it with soap and water, examine it in the light, powder it with Faultless Starch, and put it back into your case until you’re ready to use it again.”

One of the girls learned back against the wall and closed her eyes. She might have been thinking about her baby, about the radical course her life had taken, or for all I know she might actually have been thinking about the maintenance of diaphragms.

Mrs. Peak finished up with a little homily on how important it was for the girls to provide their own children with some form of sex education, implanting a suggestion that it was up to them to break the cycle of teenage pregnancy. They seemed in their vague way to accept her advice, to agree that their situation was a matter of real concern. When she asked for questions, they had none, so she began putting her birth control samples back into their carrying case. The girls sat there for a while after she left, looking dreamy, shell-shocked, as innocent in their way as the babies they had just brought into the world; then they stood up and walked painfully back to their rooms.

A baby born in good health at JD is moved, after its stay in the Transitional Care Nursery, to the main nursery, known as Newborn One, or to the rooming-in facilities in the old maternity wing. Those who need more attention are moved up from ICU to other nurseries known as High Risk, Low Risk—where babies born addicted to heroin are given paregoric to ease their withdrawal—and Low Birth Weight, where premature babies may spend months before they weigh enough to be discharged. Parents are encouraged to visit their babies in Low Birth Weight in order to participate in the crucial bonding that an infant requires in the first months of its life. Many parents do come in, of course, but it is not uncommon for babies to be left weeks past their release date with no word from the mother or father. Last year five or six babies were abandoned entirely.

Neonatal ICU is the crucible through which many of these babies pass in the first days and weeks after birth. I found it to be an outwardly pleasant place, housed in a spacious section of the Wallace Maternity Center, next to the delivery corridor. Inside the dozen or so incubators were wizened little human forms assaulted with IV tubes and sensors, with respirators taped into their mouths and black sleeping masks taped over their eyes. Some of them lay with their heads inside plastic oxygen domes; others had tubes running directly into the big veins in their scalps, which had been shaved to accommodate them.

One baby was larger than the others, almost full-term. He was suffering from a strep infection, from which in the past babies routinely died a few hours after birth. He had been given a drug that dilated his blood vessels, turning his skin a shade of maroon that was so bright I almost believed him to be a hallucination.

“Everybody here has a certain number of defense mechanisms for dealing with something like this,” Linda Rosen, one of the pediatric residents, told me when I asked her what working here did to her state of mind. “I may call this kid the Purple Pumpkin. Another kid had a cranial depression. Somebody called him Ashtray Head. It’s really sick, but that’s one way to deal with it.”

Rosen began to draw blood from a tiny baby that she suspected of having had a brain hemorrhage. With both hands in the incubator, pricking the baby’s foot with a needle, she reminded me of someone trying to build a ship in a bottle.

“He’s not doing much better,” she said. “He’s had some seizures and a low calcium count. I’ve had a hard time controlling that. He had some protuberance in his stomach but I think he just had a hard time with a glycerin suppository.”

I asked Rosen about the baby’s mother. She said she hadn’t been able to contact her. “She doesn’t have a phone and doesn’t speak English. The other day I got the Spanish interpreter to write a letter for me saying, ‘Your baby is ill, please come in.’ Since then he’s had a head bleed; that changes the picture some. If she doesn’t come in soon, I may have to write another letter to tell her that the baby’s dead.”

ICU is one of the places where the personnel shortage is most critical. The accepted nurse-to-patient ratio in a neonatal ICU is one to two. It is common for the ratio at JD to be one to four, with some of the nurses—hired on a short-term basis from a professional agency such as Nursefinders—having no experience in neonatal intensive care.

“One night,” a doctor told me, “we had eight kids on respirators, and we had two nurses and one medical student to deal with them. That’s it. It’s so blatantly, obviously ridiculous. You have a doctor walking lab work to the lab because there is no ward clerk to do it.”

The ICU doctors complain that the administration is not aggressive enough in trying to hire nurses, that they are out of touch with the day-to-day realities of the hospital. “I feel strongly that there could be more money available if someone cared enough to look for it,” one of them said. “If one of the county commissioners’ wives had a baby in this hospital and had to be cared for in ICU you can be sure they’d find the money someplace.”

I came in a few days later and saw that the Purple Pumpkin’s condition was even more hideous. He had been given a drug to paralyze his voluntary muscles, and he lay still on his back with his arms spread while various life-giving fluids and drugs coursed through his body. They had removed the oxygen dome and put a tube through his nose and pharynx to reach his trachea; almost every inch of his body was invaded by some sort of monitoring or supporting device.

“As sick as he is,” Todd Scharnberg, a doctor at JD on a neonatology fellowship, told me, “I think everyone around here is surprised he’s still going.”

Another baby, a girl, lay dying in an incubator that had been placed off to the side, as far away from the occasionally bustling center of the unit as possible. The baby’s parents sat there watching her, as they had done for three days now.

From the other side of the room Rosen noticed that all the instruments attached to the baby had stopped registering. She conferred with Scharnberg for a moment and then walked over to the parents, putting her hands on their shoulders, and telling them what they seemed already to know. They each nodded. The mother’s eyes were rimmed with red, but she sat there without crying as Rosen opened the door of the warmer and began pulling all the tubes from the baby’s veins. She cleaned the body off, washing the dried blood from the scalp where the IV tubes had been implanted, wrapped the baby up in a blanket, and turned off the light in the incubator.

The Purple Pumpkin lived for one more day.

Out in the hall nurses were shuttling babies around from nursery to nursery in little crib-carts covered with pink or blue blankets. I followed one of them down to Newborn One. There were about fifty babies there, lying side by side in their clear plastic troughs, trussed into place with blankets. It was just after feeding time, and all of the babies were asleep. Suddenly one of them jerked his head upward and moved it from side to side, like an adult who awakens with alarm in some place he cannot recognize. The baby laid his head back onto the mattress but kept his eyes open. He seemed concerned, pestered by some dim memory of the sloshings and stirrings he had known inside the womb.

In the overcrowded parking lot someone had blocked my car with his, and while I waited for the driver to come back and move it, I stared at Jefferson Davis Hospital. It rose eleven stories above Buffalo Bayou, a typical municipal monument of the thirties, built in “modern American style” and meant to suggest, in the best ham-handed style of architectural correspondence, the shape of a cross.

It was, one had to admit, a grim-looking place, but the least that could be said for it was that life began there—into whatever circumstances—far more often than it ended. I thought of the baby boy I had just seen in Newborn One. Someday he would be traveling with his mother—perhaps she would still be a teenager—along Allen Parkway, and she would point casually to the hospital and say the words that would transform the building forever in his imagination. Look. That is the place where you were born.

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