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Home Delivery

August 18, 2011 by Mary Marvin Comments Off

When Japhy was born on March 5, 2011, he was welcomed by his mother and father and sleepy big sister, 2½-year-old Maya, who kept herself awake for her brother’s late-night debut by watching videos.

“The birth was beautiful, very straightforward and uncomplicated—a family event,” says Sarah Davis ’03, the midwife who attended the birth in San Diego at the home of parents Yukiko Honda and Doug Beacom.

“A family event” describes Davis’s philosophy about birth. “While the broader culture always considers birth to be a medical situation, we say it’s always a family event and sometimes a medical event,” says

Davis, who co-founded Birth Roots in 2008 with partner and fellow midwife Darynée Blount. In 2010, they opened the Birth Roots Health and Maternity Center in a cozy old Craftsman home in Chula Vista near San Diego.

For Davis, midwifery combines interests in women’s health and social justice she had as a student at Pomona. As a Black studies major, the historical research she did on African-American midwifery for her senior thesis sparked an interest in modern midwifery, eventually leading to a three-and-a-half-year apprenticeship with a midwife in San Diego. “Once I started attending births,” she says, “I knew I loved it and couldn’t imagine doing anything else.”

Now Davis helps others follow her path. Birth Roots has two student midwives who are enrolled in school and participate in prenatal visits and births. “That’s what I do to keep midwifery going,” she says. “I’d love to see a midwife on every block and a birthing center in every neighborhood. If you need medical care, you’re going to get it, but I look forward to the day where a hospital birth isn’t the expected routine.”

After being a part of an estimated 300 births, Davis knows to carefully tend her calendar, and not just because infants can arrive at any crazy hour. The midwife role also carries some special social obligations. “I get invited to a lot of first birthday parties,” she says.

The Dad Who Knew Too Much

August 18, 2011 by Nathanael Johnson '01 Comments Off

The polarized history of birth politics is neatly contained within my family. I was born in a second-floor bedroom, with candles burning and The Chieftains on the turntable. My wife, Beth, was born at a hospital via scheduled cesarean section, without musical assistance. My parents were hippies. Hers were Republicans. In our respective rebellions, we met somewhere in the middle. Both of us lacked the fervor that had divided the previous generation during the culture wars of the ’70s. She, a nurse, was aware of the occasional excesses of modern medicine, and I, having spent my childhood testing the beneficence of nature, no longer believed that “natural” was synonymous with “healthy.” Nonetheless, before we went to our first prenatal appointment in December, Beth asked me not to say anything crazy.

“What do you mean?” I asked, aghast.

“I just don’t want you to go into investigative-reporter mode on the doctor,” she said.

For the last few years pregnancy and birth has been my beat as a journalist. It began when a source showed me the findings of an unreleased report from the California Department of Public Health revealing that the number of women dying from causes directly related to pregnancy had more than doubled in the previous decade. The researchers immersed in this data said that this statistic was probably the most visible sign of much more widespread problems haunting maternal health care.

The U.S. is now the most dangerous developed country in which to give birth, and by far the most expensive. Usually money is the fulcrum of the health-care debate–we argue about how many we can afford to cover with insurance, and about who should get the benefit of expensive new tests and drugs. But as I reported a series of stories on maternal health it became clear to me that access to health care is beneficial only if the quality of that health care is good. And quality, it turns out, is highly variable. Even the best hospitals regularly perform procedures with no basis in scientific evidence.

My reporting, done from an abstract height, took on a new immediacy once Beth and I entered the health system ourselves. It was pretty hard to question the standard treatment at all without violating Beth’s directive against sounding like a crazy person. Hospitals, both for better and for worse, are industrial systems. They are optimized for efficient treatment, and not for patients who want to examine the science backing each routine procedure. They run most smoothly when patients have faith in their efficacy. It’s rough going for patients like me, who would rather leave faith out of medical decisions entirely.

It hadn’t taken much research to see why medical authorities tended to think home-birthers like my parents were crazy. Maternal mortality peaked in this country around the turn of the last century, when more than 800 women were dying for every 100,000 live births. Since that time, it has fallen more than 99 percent, reaching its nadir in 1997 at 7.7 deaths per 100,000 live births. Infant mortality fell a little over 90 percent in that time period. Clearly, obstetrics has been wondrously effective–so effective that some practitioners feel they can legitimately dismiss any complaints about modern childbirth as frivolous.

These improvements have coincided with a shift in obstetrics toward more technology and greater standardization. Rather than adapting techniques to the vagaries of each birth, doctors have sought out methods that yield reliable results regardless of context. In pondering this trend, the physician-journalist Atul Gawande showed that the cesarean surgery was one of the best methods for bringing standardization to birth. It’s easy to learn, and it replaces the atavistic complexities of mammalian reproduction with a few legible, controllable steps.

In a 2006 article for The New Yorker (titled “The Score”) Gawande asked if there was anything wrong with this: “The question facing obstetrics was this: Is medicine a craft or an industry? If medicine is a craft, then you focus on teaching obstetricians to acquire a set of artisanal skills–the Woods corkscrew maneuver for the baby with a shoulder stuck, the Lovset maneuver for the breech baby, the feel of a forceps for a baby whose head is too big. You do research to find new techniques. You accept that things will not always work out in everyone’s hands. “But if medicine is an industry, responsible for the safest possible delivery of millions of babies each year, then the focus shifts. You seek reliability. You begin to wonder whether 42,000 obstetricians in the U.S. could really master all these techniques.”

Gawande concluded that, notwithstanding a romantic twinge at the thought of losing human connection to yet another natural process, it was the quantifiable results of improving infant health that had driven this industrial revolution in hospitals–and who could argue with that? Though several years have passed since the publication of this article, it’s worth considering here because it epitomizes both the way most medical institutions frame the issue of C-sections to this day, and the error that undermines that framing. This error is a willingness to allow the logic of industrialization to drive medicine (or the reasoning in a magazine story), while failing to use that same logic to check the results. And checking isn’t so hard.

Medical researchers, thanks in large part to the work of Donald Berwick (now running Medicaid and Medicare for the Obama administration), have increasingly embraced the discipline of quality improvement, a set of techniques borrowed from industrial engineering. Quality improvement seeks out measurable benchmarks to show if reforms make things better or worse. These data allow administrators to see problems that are otherwise invisible–either because cause is separated from effect, or because they defy conventional wisdom. “The Score” focused on one such measurement, the Apgar score, which quantifies the health of a newborn on a scale of 0 (limp and blue) to 10 (pink and wriggling). And while Gawande showed how attention to this measurement could drive doctors to do more cesareans (on this point he is typically brilliant), he didn’t mention that as the cesarean rate rose from 15 percent in 1978 to 32 percent today, overall Apgar scores did not budge. In other words, quantification may have caused more surgeries, but those surgeries didn’t produce a quantifiable improvement. There are also other measurements used to determine the success of obstetrics. One is maternal mortality.

This article came up when I met with Aaron Caughey, head of obstetrics at the Oregon Health and Sciences University (at the time Caughey was at UC San Francisco). Gawande and Caughey had gone to Harvard Medical School together where they had become friends. “So did he call you when he was writing ‘The Score?'” I asked. Caughey shook his head. I wondered if he thought there was anything more to be said on the subject. “I think there is,” Caughey said. “I mean it was a great article. But most people have been missing something when it comes to C-sections.”

Caughey’s research predicts that if we brought the national C-section rate down to 20.6 percent by 2020, every year we’d be saving the lives of 110 moms who would otherwise die as the trajectory continued upward. These deaths are almost nearly impossible for doctors to see because most complications and injuries stemming from cesareans do not appear until the next birth, or the one after that. By performing the surgery an obstetrician can lower the risk that anything going terribly wrong, but she passes an increased risk on to the next doctor–not to mention the patient.

Caughey said it would be “really, really easy” to bring the national cesarean rate back down to 20 percent–meaning that doctors and hospitals have the tools they need to safely perform more natural births. Other quality improvement reformers have come to similar conclusions.

Intermountain Healthcare, a nonprofit hospital system based in Utah, started on a new course more than a decade ago, after the industrial audit recommended more “low-tech, high-touch” births. Intermountain focused most of its efforts on reducing the number of babies unnecessarily delivered early (either via cesarean or induction). Bryan Oshiro, who worked for Intermountain as a neonatologist in the early days of this project, told me a story of the defining experience that had made him an evangelist for this issue. The head of the neonatal intensive care asked him to look in on a group of babies with problems.

“He said, ‘You doctors are doing this. These babies are here because you allowed them to be delivered early,'” Oshiro said. “That just kind of stopped me dead. It was really clear–we’re hurting babies. And we can stop it.”

The effects of the changes were wholly positive. Mothers, on average, were able to go home sooner. Complications and admissions to the neonatal intensive care unit decreased. C-section rates declined. But there was also a hitch: The reforms have reduced the amount Intermountain charged its patients by more than $250 million since 1999. “Intermountain is nonprofit and that makes it easier for us to take such steps, but the incentive for most organizations is to provide more care, not less,” Intermountain representative Daron Crowley told me.

My own analysis showed that a pregnant woman walking into a for-profit hospital in California was significantly more likely to have a cesarean surgery than a woman walking into a hospital without an incentive for profit. I doubt that doctors are the mechanism driving this disparity (they usually receive about the same reimbursement regardless). But it is clear that nonprofit hospitals are the ones adopting these reforms. I imagine it would be hard to convince any hospital administrator to adopt a low-tech birth program that costs money, sometimes alienates doctors (no one likes to be told they are doing things wrong), and (oh by the way) reduces revenues by millions of dollars. But it would be especially hard if that administrator’s performance was measured by hospital profits.

As my wife and I began talking about where she would give birth, all this was troubling. Of course, we could have simply opted out of a hospital birth entirely. That’s not as foolhardy as those statistics at the beginning suggest. One point usually left out of the improvement-of-obstetrics story is that obstetric practice itself was responsible for a large part of those shocking turn-of-the-century statistics. In a 1999 review of the century’s improvements, the Centers for Disease Control concluded that “Poor obstetric education and delivery practices were mainly responsible for the high numbers of maternal deaths, most of which were preventable.”

Uneducated midwives were certainly part of the problem in those days when the majority of births occurred at home. But historical examples suggest home births weren’t the crux of the problem, as in the well-documented case of Eastern Kentucky’s Frontier Nursing Service, which, starting in the 1920s, made it safer to give birth in a log cabin, attended by well-trained horseback midwives, than in the best hospitals in the city.

Even today the evidence is perplexingly mixed on home birth. The people who do meta-analyses of all the various studies (like the Cochrane Systematic Reviews) basically say that–for a low-risk pregnancy–it’s a wash. There’s insufficient evidence to advise patients that it’s safer to give birth in a hospital or home.

Beth and I were left to sort out the choice on our own. It made intuitive sense that a hospital would be safer in an emergency–I could think of several conditions (an undetected placental abruption for instance) where you would want to be seconds, rather than minutes, from an operating room. On the other hand, I’d also interviewed the families of women who had died because of mistakes made in the bustle of hospitals. I found I was weighing Gawande’s rhetorical question: Do we go with craft, or industry?

It’s a question that reformers now are asking about the entire medical system. Ideally health care would be post-industrial, assuming either form depending on the circumstance; it would be nice if medical record-keeping worked with the effortless efficiency of industry, while office visits emphasized the personal touch of an artisan. Family medicine and psychiatry–craft; surgery-industry. But if we treat all medicine as an industry, as is increasingly the case, it would behoove the country to also adopt the best practices of industry–to make decisions based on evidence–rather than simply using the metaphor to justify a reliance on technology. Any industrial system is by necessity reductive, it boils complexity down into measurable numbers. At the very least we should pay attention to what those numbers are telling us.

One of those numbers is cost. In the United States maternal mortality is the most salient example of our health care paradox–the more we spend the sicker we get. The costs of maternal and infant health have grown to absolutely astronomical levels, while the outcomes have stagnated or gotten worse. Troubling as they are, the rising maternal mortality statistics are also an opportunity. If we can figure out what is happening in reproductive health then we will have a set of tools to make health care better and more affordable.

But this is a challenge for policy makers and hospital administrators. It’s not easily undertaken by individual patients. There’ no place for nuanced discussions about quality improvement during prenatal checkups. The only thing that seemed within our power to control was our choice of systems–or of faiths, if you will. Neither my wife nor I wanted to place our trust in the power of The Chieftains, but we also didn’t want to be nudged into a cesarean surgery by a health system with policies based on industrial logic rather than science. In the end, the idea of giving birth in a hospital just seemed a little more comfortable–a little more safely mainstream. It’s frustrating, but despite all the statistics and studies, we ended up making the one choice available to us based on a gut feeling.

Nathanael Johnson’s reporting on maternal death rates for the non-profit investigative reporting outlet California Watch appeared last year on the front pages of newspapers across the state, from the Sacramento Bee to The Press-Enterprise of Riverside.

Untimely

August 18, 2011 by Sally Ann Flecker Comments Off

On June 15, 2008, the day that everything changes completely and irrevocably for Mariah King Steinwinter Kochavi, the 28-year-old Army veterinarian is at a remote mountain inn in the Andean highlands. It is Sunday, her third full day in Peru where she has been trekking from lodge to lodge along an ancient Incan stone-paved path. The hikes are beautiful and demanding, up and down steep slopes that will ultimately lead her group to the legendary city of Machu Picchu. Along the way, she is likely to see more mountains than people. It is a true getaway, marred only by the migraine that has nagged her since her arrival in Lima late Thursday night. Migraines are something Mariah has grappled with since childhood. This one is relentless, but she isn’t about to let it hold her back.

Besides, everyone seems to think it is probably a reaction to the changes in altitude that will go away once her body adjusts to the thinner air. Mariah had flown in from Washington, D.C.(altitude 25 ft.) to Lima (5,079 ft.), then traveled the next day to the smaller town of Cusco (11,200 ft.) where the group she was with cooled their heels for a day to get acclimated. That Sunday, their hike takes them to 14,000 ft. Despite the powerful headaches, Mariah is out in front of her group. The evening before, she did take some Tylenol, but had shaken off the offer of altitude sickness tablets. She wants to tough it out. Part of the allure of the trip, you see, is seeing how her body performs in extreme conditions.

Mariah has been pushing her body to extremes since she put on her first pair of toe shoes in ballet class. After a dancing injury sidelined her, she took up taekwondo where she worked her way up the nine grades to a black belt, suffering through at least one broken nose. At Pomona, she hooked up with students who were in ROTC and took 5 a.m. boot-camp-style workouts with them. She was so sure of her physical prowess that when she applied for a highly competitive Army Vet Corps scholarship to pay for her last three years of veterinary school, she fantasized about the military awarding the scholarship based on the number of push-ups an applicant could do in two minutes.

This trip is a breather for Mariah at a stressful, but thrilling, time in her life. She has just completed her first army veterinarian post at Fort Meade in Maryland, about 30 miles from Bethesda where she had grown up. A few months earlier, she had separated from Ramon Kochavi, her husband of eight years, whom she met and married while she was still a student at Pomona and he was finishing up at Claremont McKenna College. Leaving Ramon was not an easy decision. “I feel like I just left my best friend,” she confided to her mother, Mary-O King. But the compulsion to be free was too great. Says King: “She wanted to soar like an eagle.”

The Army had turned out to be an unexpectedly good fit for the young woman raised as a Quaker. She thrived on its discipline and loved the family environment of the military. She set her ultimate career sights on being head veterinarian at the Armed Forces Institute of Pathology on the Walter Reed campus. In the meantime, she was about to be deployed to Egypt’s Sinai Peninsula, where there are two multinational base camps and 30 observation posts. “My job will be to take care of some fifty to sixty ‘mascots.’ These are ‘dogs’ adopted by soldiers and ‘trained’ to ‘guard’ the observation posts,” she wrote in an email shortly before her trip to Peru. “For all I know they are actually rabid foxes or rogue camel spiders—go ahead and google it—the soldiers trap for entertainment value.”

Her responsibilities were to include serving as camp veterinarian for public health issues (“i.e. rabid mascots and camel spiders,” she wrote) as well as approving the farms and factories throughout Egypt and Israel that supplied food to the troops. The new job would be a challenge. That was the point.

When she left for her vacation in Peru, she was doing what we all do—fussing with the stubborn details of life that seem to matter so much at the moment. She had to figure out what to do with her Subaru, make arrangements for someone to take care of her dog Chai, get everything packed up and shipped to Egypt. Everything is about to change for Mariah. But it isn’t the change she has in mind.

A young Mariah—she’s 6—is hiking in Rock Creek Park in Washington, D.C., with her mother and younger brother Clay. It’s a damp Saturday in March. Clay, who is not quite 4, is dragging his feet. Bunny—the nickname Clay gave Mariah before he could say her name—is way ahead. She has found a new walking stick and is holding a white balloon she had fished out of the creek. Eight riders on horseback suddenly appear in front of her, but Bunny isn’t daunted in the least. She is determined to be the first one back. That’s all that matters to her. Her mother remembers this particular day from 25 years ago. “Being way out in front is exactly what she was doing on Machu Picchu,” King says. “It strikes me we were all always trying to keep pace with Mariah.”

The great themes of Mariah Steinwinter Kochavi’s life surfaced— and merged—in childhood. This is no small point. Many of us follow along one path in life and eventually find that it leads to another, unforeseen one. We encounter moments where we make choices that change us, for better or worse, into a person we didn’t exactly expect. Mariah, on the other hand, was like an acorn—always destined to become an oak tree. Looking back at her childhood, you can see present all of the elements that define her in adulthood. She had an acute intellect, which was matched by great physical ability. She was inordinately proud of both of these traits and subjected both brain and body to strenuous workouts.

“Once Mariah chose a path, she finished—and with gold stars,” says her father, Mark Steinwinter. “Her M.O. her whole life was to be the best that anyone was in an area. Achieving things was huge for her.” Paradoxically, achieving them quietly was equally important. After her parents divorced, her mother moved the family several times. If there was a basement room, she’d claim it for herself, says Clay. Even in childhood she was a deeply private person, disappearing for hours at a time into her little nest where she would read, or sketch, or paint—she was always working on something. She kept what she was working on to herself until she had perfected it. Not for show was the messy process of learning, of practicing something over and over until you get it right. “She would decide she was going to do something and develop it in private and in secret,” Steinwinter says. “Then, when it was a fait accompli, she would expose it with a flourish.”

Mariah’s fascination with animals, particularly birds, goes all the way back to when she was in a playpen looking out into the back yard. Every time she saw a bird, she would bounce up and down and clap her hands. She would grow to observe nature keenly, drawing and painting birds and flowers in exquisite detail, and when she was only 8, her watercolor of a ruby-throated hummingbird landed on the cover of the Massachusetts Audubon Society’s magazine.

She began rescuing animals at an early age, starting with two baby robins whose nest was blown out of a tree during a storm. With the help of her mother, Mariah fed them almost round the clock, keeping them safe while they developed their pinfeathers. There were many more rescues—like the sparrow she saw fly into a moving car one day on Wisconsin Avenue in Bethesda. She begged her mother to step into the street to retrieve it after it lay limp on the ground, then Mariah sat under a tree holding it. Back home, she made a cage out of a box and some netting, poked sticks through a small hole for perches, suspended a piece of lettuce from a string, and named it “Survivor”—a testament as much to her own resolve as to the tiny bird’s life force. She didn’t give up on it. She never gave up on anything.

The idea of going to vet school didn’t occur to Mariah until her final semester at Pomona, where she graduated with a degree in German studies and a minor in art. Actually, vet school was the brainstorm of Ramon, who believed Mariah would eventually become bored with her original career goal of becoming a scientific illustrator. Besides, being a veterinarian had been his own youthful dream. It’s kind of funny the idea hadn’t come up earlier, if only to spare the couple the vet bills for caring for the menagerie that shared the one-bedroom apartment with them— love birds, sugar gliders, ferrets, an iguana, a bunny and an umbrella cockatoo.

By then she had missed the application deadline for all the vet schools but the Cummings School of Veterinary Medicine at Tufts. She sent off her application, considering it a practice run for the following fall. With only 28 vet schools in the United States, getting accepted is even harder than getting into medical school. But on the very day of her graduation from Pomona, she received an acceptance letter from Tufts, giving Mariah and her family, who had gathered for the occasion, a double reason to celebrate. Vet school offered Mariah the perfect combination of intellectual challenge and immersion in all things animal. She took to it like a fish to water. “My favorite new muscle (who has a ‘favorite new muscle’?) is the buccinator,” she wrote in an email at the end of her first semester “You say it ‘buxinator.’ Just for comparison,my favorite muscle used to be the calf. I like doing calf raises while I brush my teeth. Now I’ve learned the muscle I thought all along was the calf is the gastrocnemius and the superficial digital flexor along with it, if you’re a cat but not a dog, the soleus. I can’t summon the will to do gastrocnemius/superficial digital flexor/soleus raises while I brush my teeth.” Who could?

The hands-on part of her veterinary education involved rotations in a variety of places—at the Bronx Zoo, in the Florida Keys, on a kibbutz in Israel, not too far from where Ramon’s parents live. Her favorite, says her father, was working at Tufts’ Wildlife Center where people would bring in wild animals from the hills of central Massachusetts. “There wasn’t really a protocol,” Steinwinter says. “Mariah especially loved working on those beasts because there was nothing to go on. She had to use all of her intuition and sensitivity and her scientific background to figure out what’s the right thing to do for this crow or this raccoon.”

Mariah never grew out of the impulse to rescue animals. But she did come to understand the fine distinction between giving up on something and letting go of it. Her mother called one day to tell her that Guy, a pet cockatiel she had since she was 9, was not perching. He was just sitting in the bottom of the cage, which is not natural, and King could feel a tumor under his wing. After a long-distance consult with the vet about the possibility of doing surgery, Mariah told her mother she should put the bird down. “She said to me, ‘He had a good life, Mom. Let him go,’” remembers King. It’s a conversation King will have reason to recall frequently.

That Sunday in Peru, after the morning’s strenuous hike, everyone in her group settles down at the lodge for an afternoon nap. Mariah can’t sleep, though. She gets up, goes out for a walk, takes some pictures. Later, when her friend Molly Harrington comes back to the room to check on her, she is relieved to see Mariah in bed, having apparently finally fallen asleep. She hadn’t slept well the entire trip so far. When Harrington tries to rouse her to ask about dinner, Mariah, who never drinks, sounds drunk and confused. Thinking she is showing signs of serious altitude sickness, Harrington races off to get their guide. When the two try to help Mariah stand up, she slumps down as if she’s fainted. The guide gives her oxygen to stabilize her and make plans to take her back to lower altitude in Cusco.

What follows is a long, jarring, winding journey over rough terrain. Harrington has to hold Mariah up because she isn’t able to do it herself. Mariah jokes about her tongue being numb, and covers her eyes because everything is blurry. It takes two hours just to get to an exchange point where they are met by the closest thing they have to an ambulance. The ride to Cusco, where there is a traveler’s clinic, is another hour-and-a-half. Mariah asks Harrington if she has had a stroke. Indeed, this will turn out to be the case. But at the moment it is unthinkable to everyone but Mariah. It will be more than another 24 hours before doctors make the shocking diagnosis that this vibrant young woman who was hardly sick a day in her life has suffered a brain stem stroke. One of the arteries feeding her brain was narrowed—probably a congenital condition. But for whatever reason—the altitude, birth control pills, nobody will ever know with certainty—it became blocked, cutting off oxygen to her brain and causing grievous damage.

It is not until Tuesday night that her family gets the news. Her father jumps on the next plane to Lima. By the time he arrives, Mariah has deteriorated even further. She is now in intensive care, breathing with the help of a ventilator. She is virtually paralyzed, wracked with vicious muscle spasms, but able to talk .She asks her father to take her home. Later, he is floored when she tells him to kill her if she is not better in four days. This is not the tenacious person he has always known. He asks her to be patient, to see how things are in six months. The next morning, when he comes back to the hospital, she has been robbed even of her speech. Cruelly, the only thing left intact is the cognitive part of her brain—the part where she can see clearly what she has lost.

It’s a formidable road that stretches out before Mariah. She is receiving the best care in the world, first from Walter Reed Army Medical Center where she was flown to as soon as she could be moved from Lima, then at the polytrauma rehab unit at McGuire Veterans Affairs Medical Center in Richmond, Va. There she undergoes five months of intensive therapies—physical, occupational, speech, kinesiology and recreational therapies. Finally, she returns to the Walter Reed campus to live at the Mologne House, a kind of assisted living hotel, where she will continue the recovery process as an outpatient.

The prognosis is not terrific. At first she can only communicate by wiggling her feet—she wears one sock that says “yes,” the other “no.” After a few months she regains her ability to speak. She calls it a “Mariah-cle.” But the production of sounds is labored; the old musicality to her voice gone. She has to relearn how to walk, how to reach for things, how to brush her hair, how to swallow. She has always been a voracious reader. Now she not only has trouble holding a book up to read, but she has double vision. The most doctors can do for that is suggest an eye patch. Damage to her vestibular system, which contributes not only to her balance but her sense of where her body is in space, is profound. She is afraid of walking on her own, terrified that she is going to fall and hurt her head. Still, everyone who knows Mariah holds the same thought: If anyone can beat the odds and astound the medical experts, it will be Mariah.

But it’s not like that at all. She is profoundly depressed, even suicidal, from the first. She does make slow, but marked, progress, meeting one milestone after another—sitting up, holding a fork, walking with assistance, maneuvering her wheelchair. In her old life, she would often throw her kayak on top of her car at the crack of dawn and head out for a solitary morning of paddling and birdwatching. As part of her therapy, she gets back in a kayak, courtesy of a volunteer program run out of Walter Reed. Kayaking is an excellent way to rebuild core muscle strength and confidence, Mariah starts out in an indoor pool with a specially outfitted kayak, but eventually kayaks in the C&O Canal and the Potomac River. She also participates in equine therapy at Fort Meyer, which puts her back among the familiar smells and sounds of a stable. She works her way up to a point where she is able to ride solo—a stunning achievement.

But all of this progress seems lost on her. In fact, she continually rejects the notion that she has made any progress at all, denies taking steps on her own or kayaking on the canal—perplexing everyone who has worked with her and witnessed her achievements. “I don’t know if it was because she was holding out for being back where she was and even better—which was never going to be in the cards,” says her father Mark Steinwinter. “Or if the stroke itself had robbed her of the rational ability to see what was and measure it against where she had been.”

Truly, her losses are staggering. Yes, she can talk—quite intelligibly if she talks slowly and if the listener pays good attention. “It was miles from the articulate, witty, brilliant Mariah that she liked to project,” says Steinwinter. Her occupational therapist brags about the snowman Mariah drew one day during a session— a noteworthy accomplishment in her recovery. Still, can Mariah have heard that praise without grieving for the lost pleasure of sitting cross-legged on the grass with a sketchbook in her lap while she captured the fine details of a rose about to bloom?

There are collateral losses as well—the privacy she so prized, for one, and, too often, her dignity. One afternoon her mother took her out for lunch at her favorite delicatessen. Afterwards, they decided to get manicures at the nearby salon. “Such a good girl,” the nail technician cooed to this brilliant, sophisticated woman as though she were a child.

A few months after the stroke, doctors tested her cognitive functions. “I’m still the smartest girl in the world,” she told Steinwinter when she was wheeled back into her room. “She had memory that scored her in the 99th percentile of people who have not had strokes,” he says. It was on her intellect, finally, that she pinned her hopes. She wanted to get back on track with her veterinary pathology career. One of the giant roadblocks to this goal was that she didn’t have the fine motor coordination to write; in fact, even using a keyboard was a challenge for her. She suggested trying speech recognition software, and when she first tried it out she was able to compose a nice message to her brother.

“We were both elated. Maybe it wasn’t necessary for her to be able to write really well to be successful professionally,” Steinwinter says. “She could do it this way. I know that just filled her with a lot of hope.” He bought a high-end laptop for her and loaded it up with the speech recognition software and took it to her the next time he went to see her, a few weeks before Thanksgiving. “The plan was to see if she could also do some veterinarian transcription type stuff,” he says. “She was eager to have a go at it.” But this time around, for whatever reason, her speech was off just enough that the system didn’t do a good enough job transcribing what she was saying. It was frustrating, but she kept at it for hours—to the point that she was barely intelligible.

“Here was the problem,” says Steinwinter. “A few weeks earlier there had been this giant breakthrough and all the hopes that went with it. And all of a sudden she was crashing into a wall. I think that did two things to her. It robbed her of a technical solution to a problem. But it also isolated her further and just reminded her—other people have trouble understanding me and so does the computer and here I am stuck in this awful situation.”

Mariah has spent her whole life on a mountain. On the rare occasion that her smarts and strengths didn’t carry her all the way to the top, the sheer force of her will made up the difference. Now picture Mariah sitting there at that computer, trying to train it to recognize her voice—a voice she couldn’t quite control, a voice she herself didn’t even really recognize as her own. Imagine her talking into the machine over and over and not being able to make it understand. Imagine her heart breaking as this failure washes over her. Is she giving up—or is she letting go?

One afternoon, Mariah and her mother are sitting in companionable silence in Mariah’s room at Mologne House. “What are you thinking about, Mariah?” King asks. “I’m thinking I had a wonderful life before the stroke,” she answers. Her mother can’t help but remember when she has heard Mariah say something like that before.

Perhaps that wonderful life—filled as it has been with dogged ambition and grand accomplishment—has left Mariah unsuited for a decidedly imperfect body, for a life that is not of her own choosing. Whatever the reason, a few weeks later, on December 24, 2009, 18 months after the stroke, while her mother is out running some last-minute errands for the holiday, Mariah makes one final, heartbreaking choice—to end her own life.

It is her mother who finds her, as Mariah must have known it would be. That morning, she had painstakingly signed a homemade Christmas card for King, made from one of her earlier wildlife drawings. “I love you, Mom,” it said, in handwriting so quivery it looked like it had been written with an Etch-a-Sketch. Now, King opens the door to Mariah’s room at the Mologne House, anticipating the holiday evening ahead with Mariah home. Moments later, she is back into the hallway, crying for help, crying because there can be no help.

In Boston, Mark Steinwinter is following his family out the door to Christmas Eve service when the phone rings. Upon hearing the news that Mariah is gone, he takes a step backwards to sit down but misses, landing on the floor.

Clay won’t learn of his sister’s death until the next day. When his father tries to break the news to him gently, Clay screams an endless, echoing “Noooooooooooo”—perhaps equal in weight to all of the hope and love the family had put into holding Mariah up until she could find her own way.

King opened the Metro section of the Washington Post the day after Mariah’s death to see Mariah’s picture front and center. Ironically, the Post has chosen Christmas Day to run a story that has been in the works for some time on the equine therapy program for wounded warriors at Fort Meyer.

In the days and months to come, King will mourn for her daughter. She will spend sleepless nights going through all of the drawings and paintings and scraps of writing that Mariah left behind, trying to hold onto her daughter, trying to not be buried by her grief.

But on this raw Christmas morning, King is jarred, and then comforted to see her daughter’s familiar face. In the photo, Mariah is wearing the softest pink sweatshirt. She has just finished grooming a gentle white horse named Minnie, her favorite, and is hugging her, her face almost buried in Minnie’s neck. It’s a beautiful photo—a benediction of sorts. She is hanging on for dear life, it seems. And she is saying good-bye.

Mariah King Steinwinter Kochavi was buried with full honors in Arlington National Cemetery, her caisson pulled by some of the very horses that she rode at Fort Meyer, including Minnie.

The Bequest

August 18, 2011 by emae2021@pomona.edu Comments Off

Leslie Farmer was a young woman on edge, awkward and eccentric, someone who didn’t fit in easily. Classmates who entered Pomona with her in 1963 recall Leslie as something of an outsider by choice—if they recall her at all. “I don’t remember seeing her interacting companionably with anyone else,” wrote one contemporary in response to my query on the class of ’67 listserv. Another could only remember her name and seeing her “lookbook” photo, but nothing particular about Leslie. Yet another classmate only had a memory of meeting Leslie in passing.

Some of Leslie’s obscurity likely stemmed from the fact that she left Pomona as a junior for a one-semester study abroad in Beirut and didn’t return for five years, staying on as a freelance reporter. But even in Lebanon, where you’d expect American expats to share a sense of camaraderie, she was hard to get to know. Editor Bill Tracy and illustrator Penny Williams-Yaqub worked with her in Beirut, and were surprised at how little they could recall of Leslie on a personal level. “Bill and I are always very interested in people,’’ says Williams-Yaqub, adding that, looking back, they both were stunned “that we didn’t know more about her.”

After she died in 2007, enigmatic Leslie left one more mystery. As the details of her estate were sorted out over months and then years, it emerged that Leslie had bequeathed millions of dollars to the College. The gift was unexpected—she had never tipped the College to her plans—and Leslie had had scant contact with Pomona in recent years. News of Leslie’s out-of-nowhere bequest, along with mention of her unusual stint in the Middle East as a student, eventually crossed my desk and set off my quest to learn more about her.

Leslie’s social seclusion and the lack of any close living relatives— she was single, an only child and both of her parents are deceased—meant some aspects of her life remained beyond reach. But her love for writing made it possible to piece together a lot of Leslie’s story from her many flecks of commentary and personal reflection still scattered around the web. It also helped that Leslie did indeed go on to forge a few lasting ties with people over the years and that, once again through the wonders of the web, some of the people who knew her best still could be found.

The Leslie Farmer found here was a talented writer, green-thumbed gardener, chronic book hoarder, pointed observer, fearless explorer of cultures and a lover of languages (studying Arabic, Czech, French and Italian at different points). It seems she could get swept up in just about anything that had to do with the life of the mind. But she also struggled to find her footing in life, following her intellectual fancies as a sort of eternal grad student. She saw the world: Her story reaches from Los Angeles to Beirut, from sand-swept Arabia to the cobblestone streets of Prague, and finally to the Garden District of New Orleans and the imposing, columned home where she died. And if Leslie never quite overcame her afflictions and limitations, she certainly did defy them. Tracy, one of Leslie’s Beirut editors, didn’t get to know her well, but he was on to something about Leslie from the start: “The first time I met her, she was painfully shy and very quiet. And yet there she was, a single woman traveling in Beirut, Lebanon … I thought, ‘there’s something here, she’s got some courage and guts.’”

LESLIE HELM FARMER WAS BORN in 1945 in Los Angeles to society-page parents and, no doubt, to plenty of drama, right from the start. Her mother was a former movie actress, Fay Helm, who appeared in dozens of films in the ’30s and ’40s, typically in smaller character parts but also in some larger roles, including one in the still-admired film noir thriller Phantom Lady (“A night he could not forget … with a woman he could not remember!”). Leslie’s biological father Jack Hardy was a prominent L.A. attorney, often in the papers, who earned the most ink for the sensational murder trial in which he won acquittal for a wife who had helped kill her brutally violent husband with a meat cleaver.

Fay and Jack Hardy divorced, not-so-amicably, shortly after Leslie was born, and Leslie would later write of how she had only seen her birth-father in a picture and had never met his family. Fay quickly remarried and, by all accounts, Leslie adored her adoptive father, Albert O. Farmer, a Beverly Hills dentist. The family lived in the rustic Mandeville Canyon neighborhood of Brentwood, and Leslie had a palomino named King and what sounded, in many ways, like an idyllic life. Years later, Leslie wrote a tribute to Albert’s gentleness and decency, praising how he could be a “‘man’s man’ and still not be a boor, a bully or domestic tyrant.” She tells of celebrating her 10th birthday in London, where her father bought her a carved wood swan she spotted in an antique shop.

But the next year, when Leslie was only 11, her father was hospitalized for a hernia operation. “Forty-eight hours later he was dead, victim of a rare blood cancer that was kicked into acute mode by the surgery,” Leslie wrote in an online posting many years later. From then on, it was just Leslie and mom. To put it succinctly, they were not close, at least by Leslie’s account.

As a teen, Leslie attended the private Westlake School for Girls in L.A., and then gained admission to Pomona. It’s not clear how Leslie decided to go to Lebanon (the 1964 Metate makes fleeting reference to her performing “songs from the Near East” at the five-college Smudge Pot Coffee House). Alan Hayes ’67 does recall that the intense and pale-looking Leslie had an interest in Islam, which was very unusual at the time, and that she once asked a Jewish student whether he spoke Arabic. According to Hayes: “Some people who were in that conversation later spoke of this as an example of Leslie’s social ineptitude, which I suppose it was, but I thought it was kind of charming all the same.”

Hayes, in fact, is the first person I came across who saw something more in Leslie, recalling her as “an original … and kind of complicated, which is to say confused, which struck me at the time, being a floundering adolescent myself, as an appealing authenticity.” And maybe Pomona as an institution saw something too: She would become the first Pomona student to study in the Middle East as part of the Experiment in International Living, according to articles from the time.

In Beirut, she took university Arabic classes and stayed with a young Lebanese woman named Fatima and her mother, forging a friendship Leslie would never forget. “Fatima was liberal, pretty, intelligent and not over-concerned at that time with religion or politics,” Leslie wrote in a letter decades later. When her one-semester study abroad was up, Leslie decided to stay. Maybe it was an easy choice: Bill Tracy, then an editor at Aramco World Magazine, recalls Beirut at that time was the place to be in the Middle East, a city so cosmopolitan that someone chatting at a cocktail party might shift from French to Arabic to English in the same sentence. There was plenty of work for journalists, as the city was home to dozens of newspapers. Among the papers she reported for from Egypt and Jordan as well as Lebanon was the Beirut Daily Star, the top English-language paper read throughout the Middle East. Aramco World, which reported on the region with funding from the massive Arabian American Oil Company, provided what might have been her most memorable assignment (still found online at www.saudiaramcoworld.com) in which she traveled across Saudi Arabia for a piece for a special issue about women in the Arab world.

“When the last vestings of the veil have disappeared, those who regret its passing will, I think, be few, symbolizing, as it does, the shadow of a time when women from the lowest to the highest, the most educated to the illiterate, were begrudged not only freedom of marriage, of association, of movement, but even the light of day,” was Leslie’s poetic ending to a piece titled “The Veil: A Darkness at Noon.”

The Arabian journey was unusual for a Western woman and, Tracy says, Leslie had to carry a letter of introduction from Aramco. “It was a little iffy,” adds her long-ago editor. She traveled with the illustrator Williams-Yaqub who recalls Leslie was “very edgy,” and then volunteers a thought: “I don’t know if she was stable. I’m not sure.” But Leslie pulled off the assignment, writing the lead-off piece for the issue, which on the cover featured a Saudi woman at school in Lebanon wearing large sunglasses instead of a veil. “Leslie is one of the few people, when she wrote something, the editor didn’t really play with it,” says Tracy, going on to note that her pieces always had the right beginning, middle and climax. “It was just structured exactly the way it was supposed to be.”

LESLIE’S OWN STORY DOESN’T hold together quite so neatly and proportionately. It is known that Leslie came home from the Middle East by 1971 and Pomona allowed her to resume her studies, which was no sure thing after five years away. She graduated with the Class of ’72 with a degree in English. After that she settled in the San Francisco Bay Area, but her undertakings for the next two decades can only be lightly traced with help from a few scattered class notes she submitted to this magazine. In 1976, she wrote in to say she was pursuing her master’s in communications at Stanford: “I have just sent out a fresh flock of poems to various magazines, and while awaiting the first rejection slip, am growing bulbs indoors and learning to play the corrugahorn.” Two years later, she reported she was doing much the same thing—writing poems and sending “I-toldyou-so letters” to editors regarding Lebanon after civil war broke out there— except she had now dropped out of Stanford.

Perhaps it is no coincidence that it was in 1991, near the end of this long, possibly difficult period, when her time at Pomona and in the Middle East may have seemed more and more seminal, that she laid out her estate plans. Half would go to the College and the other half to Fatima, the old friend from Lebanon she had kept in correspondence with. Leslie’s last class note, in 1992, is particularly cryptic, as she writes of hoping to “bench press her own weight and see spring in Damascus in the forseeable [sic] future.”

Within a few years Leslie would indeed find her spring, though in Prague instead of Damascus. The mid-’90s would bring Leslie a new obsession—the Czech Republic—and a new friend. And if her interest in Eastern Europe seemed to come out of nowhere, her friend Jarmila Marie Skalna explains that Leslie’s Czech obsession had roots in … Beirut.

During Leslie’s time there, decades earlier, she heard the news that a 20-year-old student named Jan Palach had lit himself on fire in Prague’s central square to protest the Soviet invasion that snuffed out then-Czechoslovakia’s growing democracy movement.Palach was a few years younger than Leslie, and she was captivated by the idea that someone that age could make such a statement. Leslie’s glimmer of interest was pushed aside by other matters until, somehow, it was rekindled decades later and she went looking for someone to teach her Czech. She was referred to Skalna, a Czech writer who with her husband left her homeland and settled in the Bay Area a decade earlier. The lessons were fruitful. “She learned Czech incredibly fast and well,” says Skalna.

In 1995, Leslie made her first trip to Prague and, as Skalna recounts, she was enthralled, even leaving a poem she had written about Palach at a monument to the Czech martyr. Upon her return home, Leslie delved deeper into all things Czech: music, films and the writers Kundera and Capek. She worked and worked on her own, perhaps-never-finished book getting inside the minds of two doomed Czech soldiers as they holed up inside a church after assassinating SS leader Reinhold Heydrich in a famous World War II incident.

In this productive phase in her life, Leslie finally went back to complete her master’s degree—Skalna suggests Leslie was trying to please her mother—at San Jose State. She kept returning to the Czech Republic, managing to connect her obsession there to her work back in grad school. “I was so astounded and ravished by the baroque architecture of Prague that I somehow persuaded my department to let me do a long magazine article on historic restoration in Prague as my thesis,” Leslie wrote online. Leslie visited the Czech Republic for a third time, in 1997, this time to study the language at a school in Brno in south Moravia. She did quite well, making it to the highest level of the beginner program, and she kept in touch with Skalna by email. “She was very happy there,” says Skalna.

Leslie’s happiness came despite what Skalna calls her “obvious social problems,” and some of the students at the Czech school had names for her. What was it about Leslie? Skalna’s take is that she just didn’t make a good first impression on people. “But later on when you started knowing her and you became closer and she opened herself (up), she was very enjoyable company,” says Skalna, who wrote a chapter about Leslie in her self-published book, Who Needs Dreams?, about interesting people she has met over the years.

Well-read Leslie was not big on banter, and when she did have something to say, she was quite blunt. “She had a very, very personal opinion on everything,” adds Skalna. “She was not easily influenced by someone’s thought or ideas. … She would be a very good critic—she got right to the point.”

When it came to the Czech Republic, though, Leslie’s enthusiasm for detail overtook her ability to critique her own dense writing about the nation, says Skalna. Leslie, despite her productive freelance career in the Middle East decades earlier, didn’t get much published during this time. Still, she always saw herself as a journalist. “She wanted to be a writer,” says Skalna. “It was her inside wish.”

Perhaps Leslie just wasn’t cut out for the hassles and indignities that come with making a living as a writer, and, at any rate, she may not have needed a regular job. According to Skalna, Leslie was living off a trust fund, which it appears she carefully stewarded. In the Bay Area, she lived in a modest apartment in East Palo Alto, where the rents were lower than in Palo Alto proper and other well-off Silicon Valley cities.

The place held boxes of books, Skalna recalls fondly. When Leslie once talked of leaving her library to Skalna one day, her friend begged her not to, knowing she couldn’t handle all those tomes. Skalna did accept from Leslie some flowering cyclamen bulbs (tubers if you want to get technical) which Leslie had brought from Jordan decades ago and kept replanting. Along with books, gardening was one of Leslie’s great obsessions, and she had a knack for reviving seemingly vanquished plants. She had a particular interest in tending flowering bulbs, like the white-and-pink petaled cyclamens. Maybe that’s the metaphor for Leslie: she was not a wallflower by any means, but one of those rare bulbs, with the best of her hidden and easy to miss unless you held out for the bloom.

LESLIE PULLED UP ROOTS IN THE year 2000. She liked living in the Bay Area but felt home prices there were just too high for her budget, according to Skalna. She chose New Orleans—long a magnet for eccentric writer types — drawn by the French influences. “She thought she would be happy there,” says Skalna, who once visited her for Mardi Gras. And, at first, she almost certainly was. Leslie bought a spacious, imposing, two-story home with columns out front and located on the edge of the city’s upscale Garden District. She became an incessant poster on what became the Google group neworleans.general and sometimes attended social gatherings of its members, who wore aluminum-foil hats when they met for lunch. She soaked up the local color, donning costume for Mardi Gras and even trying out recipes for cooking nutria, the water rodents that plague Louisiana’s coast. “She loved New Orleans, she really did,’’ says Jane Dumestre, who met Leslie through the online group. About Leslie, she says, “We all have our own little quirks. I think she was just over our heads.”

Along with writing on the Internet, Leslie fired off more than her share of punchy little letters to the editor of the New Orleans Times-Picayune, like this one published in April 2003, shortly after President George W. Bush launched the Iraq War: “I can’t decide whether your March 29 headline, ‘Guerrillas aren’t fighting fair,’ is horrifying, funny or both. According to Webster’s Third New International Dictionary, guerrilla war is irregular war carried on by independent bands. In other words, not to fight fair is their raison d’etre …”

As she had for so many years, Leslie continued her practice of exchanging letters with her old friend Fatima in Lebanon. But sometime in 2003, Leslie lost touch with her and began posting urgent messages in a Google group devoted to Lebanon: “I keep getting your letters but mine always come back to me, although sent to your latest address … I’m worried that you’re in much worse health than you mention.” She contacted the Lebanese chancellery in Washington for help and even pled with radio stations in Beirut to broadcast her message. “I’m worried about Fatima, particularly as she wrote of being sick and her mother and maternal aunt died of the same disease,” read another posting.

It’s unclear whether she ever did hear from Fatima again and,even as she worried about her old friend, Leslie was facing her own health troubles. About a year earlier, Leslie was diagnosed with dystonia, a movement disorder that brings involuntary muscle contractions, which Leslie experienced in her neck and upper body. Hers was not a mild case. “She went to every doctor she could think of. There was no solution,” says Dumestre.

Spasms brought on by the disease sometimes caused her head to turn sharply to the side and, in time, Leslie began losing her ability to speak. Using her hands also became more and more difficult, beginning to cut her off from her typing, her lifeline to the world. Her emails became terse. “She was very clever in writing, but when she got sick her writings were more like pieces of broken glass,” says Skalna, who recalls crying as she spoke with her friend on the phone. “You read some small paragraph that was very bright and then she stopped writing because she was in pain.”

Amid all this came Katrina. In the days after the hurricane hit New Orleans in 2005, Skalna, back in California, hadn’t heard from Leslie, so she signed up at the Red Cross office in Palo Alto to volunteer to help in New Orleans and go look for Leslie. Before she left, Leslie, who had been evacuated to a nearby town, got a note to a church volunteer to call Skalna and let her know she was OK. Her home sustained water damage, but was standing. After Leslie returned to the city, though, her condition continued to deteriorate, and she gave up walking, even driving. At times, Skalna says, Leslie would have to crawl on her knees to get around the house.

Leslie was found dead inside the house in May 2007 after someone noticed her mail piling up. She died from complications of her dystonia, says estate administrator Michael Cooper, who adds that the official cause was recorded as asphyxia. Severe neck dystonia can affect the upper airway and bring breathing difficulties, according to the Dystonia Medical Research Foundation.

It appears that no memorial service was held—at least I could not find anyone who had attended one—and the estate handled the interment of Leslie’s remains at a funeral home just outside New Orleans. But her passing did not go completely unnoticed as the news trickled out a few months later in a Google group: “An eloquent and elegant mind that should be missed,” read one of the posts.

Later in 2007, the College received a letter stating that Leslie had left a bequest, which is not an unusual occurrence. Only over the ensuing months and years did it emerge how large and complicated this estate settlement would become. As mentioned earlier, Leslie left half to the College and half to her old friend

Fatima in Lebanon. So the estate administrator had to locate her old friend on the other side of the globe. In a sad turn, when Cooper did find her family, Fatima was in ill health, and she died only months after Leslie. It’s not even certain whether Fatima ever learned of Leslie’s passing. Cooper then had to seek out Fatima’s heirs. Add to this the complications of Katrina: water damage to Leslie’s home led to the loss of records that would have made it easier to sort out her assets, according to Cooper. Meanwhile, the estate of Leslie’s late mother, Fay, needed to be folded into Leslie’s, and valuations of numerous properties and mineral interests were required. When the last of the bequest is distributed, Pomona’s share will total upwards of $6 million.

Where will it go? As Pomona President David Oxtoby learned more about Leslie’s background and interests, he decided it would be fitting for her gift to go toward the College’s international initiatives, which will include a new foreign language immersion hall to replace Oldenborg and an adjacent center to house the College’s various internationally related programs under one roof. So the alumna who once seemed to leave such a light trace at Pomona will help change the campus’ face in a major way. And somewhere in one of those buildings, somewhere in that place, once-forgotten Leslie Farmer will be recognized by name.

Warm Embrace

August 18, 2011 by Vanessa Hua Comments Off

At the product launch this spring for Embrace, an innovative infant warmer designed to save the lives of vulnerable babies, snafus kept popping up. The electricity went out at the startup’s packaging and quality control facility in Bangalore, India. The wash-tags were printed incorrectly and had to be redone and stitched in. And when Jane Chen ’00 and her team set off to mail the very first shipment, their rented car sprang a flat, forcing the group to hail a rickshaw.

Chen, Embrace’s CEO, overcame the problems with the same determination and creativity that led her to co-found Embrace. “Everything that could go wrong did, but we were determined no matter what to deliver the product,” Chen says by phone from Bangalore. “People napped for an hour on the couch in the office, but otherwise worked through the night.”

Each year, more than 20 million premature and low-birthweight babies are born worldwide. Four million die in the first month of life because their internal organs are underdeveloped and the babies don’t have enough fat to regulate their body temperature. Survivors may grow up with severe health problems such as diabetes and heart disease–which could be prevented if they were kept warm.

However, in villages in developing nations, babies are often born at home or in rural clinics that lack incubators or use ineffective, stopgap measures such as tying on hot water bottles or keeping the frail patients under light bulbs. In the cities, hospitals may not have enough incubators, or find them confusing to use and difficult to maintain and repair.

At $200, the Embrace infant warmer is a fraction of the $20,000 cost of a traditional incubator. Resembling a tiny sleeping bag, the device uses a pouch of a wax-like substance that can be heated to keep the babies warm for four to six hours at normal human body temperature. They’re portable, safe, and easy to use and re-use.

The ingenious product has attracted widespread attention for Chen, who has been featured in The Wall Street Journal, The Economist and a segment on ABC News. She was selected as a fellow at TEDIndia–the influential conference of global movers and shakers–and as the recipient of Pomona’s Inspirational Young Alumni Award for 2011.

At Pomona, Chen, a psychology major, mentored at-risk high school students and spent a semester abroad in Nanjing, which kindled her interest in working internationally. After graduation, she headed to Hong Kong as a management consultant. After reading about villages hard hit by AIDS in China, she became a program director at a startup non-profit that funded and operated projects in education and care for children and adults impacted by AIDS, raising funds and increasing public awareness about their plight.

“I realized how lucky I was, to be born in the point one percent of the luckiest people born on the planet. I could have been born into another life,” says Chen, the daughter of Chinese immigrants. “It exposed me to the injustices of the world.”

She returned to earn an M.B.A. and a master’s in public policy in a joint program at the Stanford Graduate School of Business and the John F. Kennedy School of Government at Harvard. Embrace emerged from a 2007 class project at Stanford, where Chen, along with Linus Liang, Nag Murty and Rahul Panicker–classmates from diverse backgrounds in engineering, business, public policy, entrepreneurship and computer science–created the prototype after a trip to Kathmandu, Nepal, where they witnessed the immense need firsthand.

The road from idea to market has been arduous, taking Chen across 11 states in India, interviewing doctors, midwives and government health officials to refine the device. “We wanted to make it truly locally appropriate, rather than something we came up with in the U.S. and force-fed on the other end,” she says. Leading up to April’s launch, there were animal trials with preemie lambs in Utah, presentations of research at medical conferences, business meetings in India and distribution deals with companies such as GE Healthcare and Novartis and NGOs such as Population Services International.

Initially, Embrace is selling a version that requires 20 minutes of electricity to heat up the device, for clinics and hospitals with intermittent power. The second version, to launch in October, is geared towards home use and relies on hot water as the heat source.

“It’s a huge market, but it’s going to take convincing that community health workers should be equipped with this tool, just like a stethoscope,” says Kevin Starr, director of the Rainer Arnhold Fellows Program, which mentors social entrepreneurs, and funds Embrace through its parent organization, the Mulago Foundation. The startup, in the process of securing venture capital funding, will have non-profit and for profit arms. So far, Embrace has raised over $2 million through foundations and individual contributions.

The company will be based in Bangalore and Chen has settled into life in India with gusto and aplomb. Clad in the traditional garb of a shalwar kameez–flowing tunic over billowy pants–and climbing aboard rickshaws, she comes off as a native, says Vinod K. Bhutani, a neonatologist at Stanford University Medical Center who has worked extensively in India on health policy and education. “She blends in,” says Bhutani, also an Embrace board member. “She’s learning to communicate the body language and understand the nuances.”

After India, Embrace plans to expand its distribution into other countries throughout South Asia, China, Kenya and Uganda and eventually develop additional affordable medical technologies. “Every time we go to a clinic,” Chen says, “we see 12 other needs that could be addressed.”

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