How an inconspicuous slaughterhouse keeps the world’s premature babies alive

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LONDON, Ontario — On the night before his weekly trip into the slaughterhouse, Fraser Taylor stepped into the back of the truck to make sure everything was in place. The hold still smelled faintly of cow — a subtle whiff of something grassy — but the equipment inside seemed better suited to a day of spelunking through the sewers. There were hard hats and hoses and straps. There were huge conical tanks, and a valve-laden contraption that might come in handy for siphoning off the contents of pipes. The truck itself was white. It bore no sign of the company it belonged to or the strange journey it was about to take.

Taylor looked tired. It was almost 5 p.m., there was a snowstorm, and the team was already running late. Snow drifted down into the lights of the loading dock as Taylor slid the truck door shut. The roads would be terrible, just tire marks through slush instead of lanes. They had to go tonight, though. Lateness was not an option on Tuesday mornings. If they didn’t get onto the floor before the cattle started coming by, there would no way to load their equipment in, and they would get none of the precious liquid they’d come to collect.

It’s a substance that most meat processing plants hardly think about: Just another fluid in the fluid-filled business of turning an animal into a side of beef. But Taylor would panic if he saw any spill on the slaughterhouse floor — those lost drops could have saved babies’ lives.

This small firm had carefully courted slaughterhouses so that its workers could be allowed inside to suck this off-white foam out of cow lungs. Then, they purified the hell out of it, and shipped vials of it across Canada, and to India, Saudi Arabia, South Africa, Ecuador, and Iran, where it was shot into the lungs of struggling premature infants.

Preemies’ lungs, like the rest of them, aren’t quite ready for birth, and some — almost all of those born very early — haven’t started producing this foam themselves. It’s called pulmonary surfactant, and without it, their air sacs could collapse. In the 1980s, doctors had tried squirting surfactant collected from other creatures in through the tiny nostrils and mouths of babies with respiratory distress syndrome, while also putting them on ventilators. The transformation was immediate: Newborns went from blue to pink. Their chests filled with air.

The arrival of surfactants in the neonatal intensive care unit was “huge,” said Dr. Paul Jarris, chief medical officer of the March of Dimes. “It was an absolutely major groundbreaking development.”

It also led to a global trade in foam — an odd corner of the pharmaceutical industry whose existence depends on the whims of the livestock business. Just across the American border from Taylor’s loading dock, on the outskirts of Buffalo, N.Y., another company buys calf lungs by the truckload. A multinational corporation based in Parma, Italy — a city famous for its salt-cured ham — gets its supply by making a kind of pig-lung haggis. One American pharma giant is doing something similar with minced cattle bits, while in India, researchers are trying to suck the stuff out of goats.

But farm to pharma doesn’t quite have the same cachet as farm to table. Plenty of medications first came from natural sources — fungi or horse urine, pig intestines or plants — but we tend to try to sever the ties between our barnyards and our clinics. The premise of biotech, after all, is that nature works better when it’s re-engineered. And after decades of trying and failing, chemists have made a new kind of synthetic surfactant. This time, they say, it’ll be as good as animal foam, but cheaper and easier to mass-produce.

For now, though, the liquid has to make its way from the roar of the slaughterhouse to the sterile hush of the NICU. In southern Ontario, that has created a small, secluded niche in the ecosystem of medicine-making, less the realm of MBAs and career chemists than of an unusual sort of craftsmen. They’ve come from local factories and war-torn countries, or emerged from the piney woods close to the Manitoba line. The extraction only happens once a week, but like many jobs, it changes how you sleep and how you dream, when you see your friends and your kids. It also forever changes the way you think about cows.

“It’s something you get used to after a while … especially since you’re doing it about 700 times a day,” said Carlo Hildebrand, a musician and sometime dishwasher who also works as a foam-extractor. “But, you know, your job is to collect cow loogies. It’s a strange job.”

Hildebrand and Taylor work for a company called BLES Biochemicals, and the surfactant it produces has taken a more precarious journey than most. Others in the business tend to buy animal lungs whole; that way they can bring the organs into the lab and mince them or wash them on their own turf. It all happens at a vertiginous pace. “The lungs, they rot, they get bacterial infections, so we only use very fresh lungs, within a few hours of the animal being slaughtered,” said Dr. Edmund Egan, founder, chairman, and chief medical officer at ONY Inc., the surfactant producer near Buffalo.

BLES gets around the time crunch another way. Its workers go straight to the source, embedding within the abattoir’s production line.

That means ever-so-diplomatically tending a relationship with part of a company over 6,000 times its size. The vast majority of BLES’ raw material comes from an abattoir owned by the Canadian branch of Cargill, which is often ranked the single biggest privately-owned American company. It has over 155,000 employees in 70 countries. BLES has 30.

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The terms are all business — BLES pays Cargill for each lung from which foam is extracted, and its presence has been approved by Canadian food inspectors — but Taylor and his team envision their Tuesdays in the slaughterhouse as if they were guests. “My main job when I get to the abattoir is to not negatively impact anybody’s day at any time,” explained Taylor. “To not even be noticed would be great.” They set up their equipment while Cargill employees are still trickling in, and they don’t leave until after Cargill’s employees’ day is done. When Cargill breaks for lunch, the BLES workers do too — they try to sit in exactly the same spot in the cafeteria, to be as unobtrusive as possible — and if Cargill does overtime, so does BLES.

The arrangement had been built on a lucky phone call made by an inveterate tinkerer named Harold Nigh. He wasn’t the kind of guy you’d expect to be brokering business deals. He doesn’t much like sitting at a desk, and he often wanders. He insists that his best ideas have come to him while on 9- or 10-hour walks, along canals, across peninsulas, from one Canadian city to another.

“You simply are able to get a true sense of the curvature and the skin of the earth as you’re walking along,” he said. “Even bicycling is too fast. You miss everything when you bicycle.”

He was born at a leprosarium in Vietnam, where his father worked as a doctor, but the early exposure to medicine hadn’t enthralled him. His childhood was full of invented contraptions — automatic bed-makers, homemade gliders that never flew — and by the time he was an adult, his interests had veered toward quantum theory, aviation, and farming.

He had planned to take over his in-laws’ fields of corn and winter wheat and timothy and rye in Ontario’s Niagara Peninsula, but as Nigh put it, “You have to be a lot smarter to be a farmer than to be a scientist. I failed out early.” That left him with three daughters at home and no source of income. He had a few chemistry degrees, though, so he took a job as a postdoc with Fred Possmayer, a surfactant scientist at what is now known as Western University, in London. His task quickly became to find the lab some lung foam.

He started by immersing himself in the mom-and-pop abattoirs of Ontario. They were small operations, just three or four people skinning and cutting up cows, and Nigh would join them with a jerry can to rinse the surfactant out of the animal by hand. He paid them $10 for each set of lungs they allowed him to wash.

As clinical trials started, demand grew. In an economic downturn, smaller slaughterhouses went out of business, and Nigh found himself in a tight spot, with physicians wanting more and more surfactant while his source of raw foam was quickly drying up. Bigger abattoirs, he’d heard, were out of the question — secretive as army bases and unfriendly to outsiders — but he figured he had nothing to lose. Most of his phone calls yielded nothing. But in one case, the beef producer on the other end of the line turned out to have been a preemie himself. His eyesight was still compromised because his retinas hadn’t developed properly. He said sure, they could come collect foam for preemies from his cattle.

BLES had incorporated in 1992. When the company’s need outgrew that abattoir, the man with the retinopathy called up a relative who had some sway at an even bigger plant, which was owned by Better Beef. The extractors have been harvesting that abattoir’s lung fluid ever since, continuing after Cargill bought Better Beef in 2005. The facility sits at an elbow-like bend in the Eramosa River, just past the municipal garbage dump in the city of Guelph. It’s a university and agribusiness town about an hour-and-a-half drive from BLES headquarters in London, and over the years, the surfactant collection pilgrimage has become more frequent as the demand for foam has grown ever higher.

As distant as it now is, that happenstance conversation with the preemie-turned-beef-producer is often at the back of BLES workers’ minds. It’s both an origin story and a cautionary tale. Their work is hard, and gritty — fixing valves, putting tubes up into dead cows — but they think about it in more cosmic terms. Even the name of the company, which stands for Bovine Lipid Extract Surfactant, becomes a pun with Lazarus-like overtones: Babies get BLESed and now can breathe. Without access to Cargill’s cows in Guelph — which partially came about because someone knew what it meant to be premature — those BLESings could come to a halt.

The company’s relationship with the ag giant has been good, and the workers are very careful to keep it that way. “We’re peanuts to them. If they ever didn’t want us there, I’m sure they wouldn’t blink an eye,” said Alex Verwegen, one of the extractors.

So even after hundreds upon hundreds of repetitions, the ritual of slaughterhouse days never feels routine. On Monday nights, they stay in a Guelph hotel, to be close to the abattoir, but Taylor doesn’t trust wake-up calls from the front desk: A few times, he’d requested a call that had never come, and the company had almost lost a week’s worth of foam. He still wakes up a few times in the middle of the night, anxious that he’s overslept and the day is already a waste.

Surfactant foam looks simple enough — imagine the head on a badly poured beer — but its molecules are notoriously tricky, hard to disentangle, and harder still to make from scratch. Their entire lives take place in a constant state of in-between.

That’s partially due to their shape: They look like mutant tadpoles, each head sprouting two tails, and they take amphibiousness to a whole new level. Their heads love water, but their fatty tails can’t stand the stuff. To satisfy all the body parts involved, they become half-aquatic acrobats, with heads under the surface and tails sticking out into air, interrupting the bonds of the water molecules with their antics.

It’s a useful trick, because the inside of our lungs is lined with a thin film of water, whose surface tension pulls inward, creating a force so strong it makes it hard to inflate our alveoli. If we can’t do that, we don’t breathe. But the surfactants’ crazy dance routine — hydrophilic head in, hydrophobic tails out — creates a molecular disturbance that lowers the tension enough for us to expand those chambers and get air into our bloodstream. It’s like a biochemical hokey pokey, with lifesaving results.

The mutant tadpole structure is actually not as rare as it sounds, and it certainly isn’t limited to lungs. There are surfactants in detergents and emulsifiers, lowering surface tensions here and there, mediating between layers of this and that, living life on the edge.

In pulmonary surfactants, though, there’s a twist, and it would take researchers decades to untangle it. Early on, during autopsies, pathologists found stillborn babies’ lungs weirdly inelastic. After World War II, biodefense researchers looking into nerve gas noted that rabbit lungs oozed a mysterious foam.

It was only in 1963, at Otis Air Force Base on Cape Cod, that this research took on a greater urgency, when first lady Jacqueline Kennedy gave birth, by caesarean section, to a boy named Patrick. He was five and a half weeks premature, and though he wasn’t particularly small, his breathing was strained. The diagnosis was hyaline membrane disease.

By then, scientists knew that babies with HMD were missing some substance that helped reduce the surface tension of their lungs. Four years earlier, in 1959, a team in Boston had taken the lungs of preemies who’d died, cut the organs into tiny pieces, diluted them, and poured the resulting liquid into a Teflon trough to understand their chemical quirks. They’d seen that lungs from infants with HMD were different from those of babies who’d died of other causes — perhaps because they were missing that weird foam. But there was no replacement anyone could offer Patrick Bouvier Kennedy. The president kept asking whether his son’s brain would be damaged; the doctors told him again and again that they were just trying to keep the kid alive. They couldn’t, and he died three days after birth.

The death spurred a torrent of research, and within a few years, a team of American scientists was ready to try out their version of lung foam on babies. They sprayed their phospholipid concoction into the incubators where the preemies lay, fragile chests struggling to breathe.

It didn’t work. Ask any surfactant researcher about that 1967 trial, and the mood is bound to darken. As Possmayer, the professor whose lab was the launching point for BLES put it, “Surfactant therapy was dead.”

Collecting cow loogies doesn’t sound like the kind of job you’d want to have for long. It starts before dawn, and combines pharmaceutical rigor with agricultural aromas. The need for your work can fluctuate with the market demand for foam. It’s dirty and loud and physically demanding, and its particular technical skills aren’t necessarily sought after on resumes. So it’s not surprising that many drift into jobs at BLES, out of necessity or curiosity, confusion or luck — and almost always through word of mouth. What’s surprising is how long they tend to stay.

Hildebrand is a case in point. After high school in Toronto, he decamped to Argentina, bought a bike, and started pedaling toward Chile. There were near misses with mangy dogs, so he bought an antique sword in a flea market and duct-taped the hilt to his bike frame.

The University of Guelph wasn’t all that exciting by comparison. He took a little history, dabbled in philosophy, failed at German, and dropped out entirely after a year. “It was totally misguided,” he said. “I probably shouldn’t have been there in the first place.” He had friends in town, though, so he stayed, playing with a band called Pigeon Crime — “sort of like alternative folk music with lots of trombone.”

But there was always the lingering question of money. So, around five years ago, he took a short-term pine-cone-picking job near Dryden, Ontario, way out to the west, in the lake-studded country between Turtle River and Eagle-Dogtooth Provincial Parks. It was miserable work. He and his friend spent all day in clear-cut swathes of forest, plucking the cones off the crowns of felled pines. They were paid by the bucketful — logging companies wanted the seeds for planting — but were making well below minimum wage. “It basically amounted to like 60 bucks for eight hours of work,” he said. “It was pretty bullshit.”

He first heard about the abattoir job while standing on the side of a logging road, next to a windswept patch of ex-forest. He got a phone call from his mum, saying his uncle Harold was looking for someone to do part-time work in a slaughterhouse, would he be interested? To Hildebrand, at that freezing moment, it almost sounded cushy.

In some ways, it was. The job paid enough for him to cover his rent with one day of work a week, and was flexible enough for him to disappear westward in the summers, to work as a tree-planter and wander as he pleased. He’s been working for BLES, on and off, for the past five years.

Read more: Controversial trial of premature infants faces fresh scrutiny following release of documents

There had been many others like him. Even with the help of his own inventions — Haroldamatics, they were sometimes called — Nigh couldn’t possibly collect all the foam BLES needed by himself. So he took on others who were good with their hands, trustworthy, in need of extra cash. They were friends of his, fruit farmers out of season, a Croatian psychiatrist who’d fled the violence of the Balkan wars. There was a steady stream of students from the Toronto School of Theology, just searching for a way to earn their daily bread.

Nigh has since stopped leading those pilgrimages to the abattoir himself. “There’s satisfaction in doing it,” he said. “On the other hand, after having done it for over 22 or 23 years, I was certainly ready to let somebody else take the job over.”

Fraser Taylor’s mum is a lab technician at BLES, and he’d come of age hearing about surfactants and going to company retreats. There was still something boyish about him, but he was in his 30s now, with a 4-year-old at home, and he was in charge of the abattoir runs. “Lavage manager” was his official title, though on abattoir days he was also time-keeper, machine-fixer, worrier-in-chief. He dealt with whatever came up.

Taylor’s unbounded excitement for surfactant — expressed quietly, with a shy smile — could be hard to match. During that snowy trip to Guelph in January, the others teased him, joking that if the storm got real bad and the truck wouldn’t move, he’d make them push it all the way there to get their day’s worth of foam.

When it arrived in the ’80s, the resurrection of surfactant therapy came in the form of a few proteins that had long been considered contaminants. The failed 1967 trial had driven some researchers away, to other biochemical pastures, but a stubborn few clung on, synthesizing and centrifuging, heating and washing, trying to figure out what had gone wrong. Many were convinced they needed to separate the phospholipids — the molecular tadpoles — from the other crud that kept turning up in their samples, but nothing seemed to work.

The proteins, it turned out, were essential but unseen players in the tadpole dance — stage managers, if you will, making sure that phospholipids were in the right place at the right time. Without them, surfactants were a mess, not as effective at lowering surface tension and enabling breath. And they’d been absent in that 1967 experiment.

Their absence also explained why the early lab-concocted surfactants hadn’t worked particularly well. Originally, people like Dr. Robert Notter, at the University of Rochester, had only wanted lung foam from farm animals as a comparison to their own recipes, to prove that they were at least as good at making chemicals as nature itself. But they quickly saw they’d been beaten at their own game. They scrapped the pure phospholipids, and elevated the slaughterhouse stuff from mere foil to potential drug.

Like Nigh’s trips with jerry cans and buckets, other teams’ first encounters with the meat business had been clumsy, down-home affairs. Dr. Tore Curstedt, a professor at Sweden’s Karolinska Institute, describes driving back from the pig slaughterhouses in Stockholm and Uppsala with lungs in the back of his car, and then mincing them with kitchen appliances. Notter showed up at one abattoir in his lab coat; the workers leered at him as they fiddled with their knives and sharpeners, thinking he was some kind of inspector.

As the mystery of the proteins was unfolding, surfactants of all sorts were being tested, and they would soon trickle onto the market. Curstedt’s work with Dr. Bengt Robertson led to Curosurf, made by the Italian company Chiesi. Notter’s collaboration with Dr. Edmund Egan led to Infasurf, made by ONY. Possmayer’s work with the surfactant star Dr. Goran Enhörning led to BLES. There was also Survanta, made by AbbVie, which is often referred to as a semi-synthetic. These are all at least partially made from animal surfactant, and contain, in one form or another, proteins that help the phospholipids do their job.

Synthetics haven’t fared as well. Exosurf, for instance, was protein-less — and less effective than animal-based alternatives — and Burroughs Wellcome stopped selling it in 2001, a little over a decade after it first came out. Discovery Labs managed to make a synthetic that did contain those elusive proteins, but Surfaxin didn’t exactly take the NICU by storm when it appeared in 2012. Unable to compete with the trusty old suspensions made from animal-foam, the company stopped producing Surfaxin in 2015.

Researchers haven’t stopped trying, though. In 2016, Discovery rebranded as Windtree Therapeutics with the goal of making a synthetic that could be aerosolized, to prevent the damage that can come with threading a tube down a tiny infant’s windpipe. And Curstedt, after helping to create what is perhaps the most widely used surfactant in the world — it yielded almost $260 million in 2016, according to Chiesi’s annual report — turned his attention to making a synthetic with proteins. He thought it would take him five years; instead it took him 20. It’s now being tested in preemies.

“Cow surfactant, pig surfactant, it’s rather expensive to purify,” explained Curstedt. “It’s time-consuming, it’s expensive and you have a limited supply. From the lungs of one pig, you can treat two or three preterm babies.” To him, a synthetic, while harder to create at the outset, would be easier to make in huge volumes, and so cheaper and more accessible in the long run.

Others in the lung-foam gang don’t buy it. “They’ve been chasing a good synthetic surfactant since 1973,” said Egan, the founder of ONY. “If they want to go down that road, they can, I guess, but I think it’s a fool’s errand. But I’m in my 70s.”

Nigh also isn’t convinced that, after so many years of research and development, the resulting drug could possibly be cheap. Anyway, he’s got other things to worry about. “Now, we’re starting to have a good problem,” he said. “We’re getting close to the point where we can’t produce enough for the market demand.”

BLES, as a private company, doesn’t disclose how profitable it is, but it’s been successful enough over the last few years to warrant sending a worker to extract foam at another abattoir in Prince Edward Island. The operation there is smaller and is still just getting off the ground, so although it helps, it can’t satisfy the increasing demand on its own. For Taylor and the other Ontario foam-collectors, that means every Tuesday is show time.

They met up in the hotel lobby at 4:45 a.m. Taylor was waiting by the tourist pamphlets. It was too early for niceties. As soon as Hildebrand emerged from the elevators, they stepped out into the snow.

They made for an odd pair. Taylor was dressed the way most Canadians do for a blizzard, his coat zipped, his woolen hat pulled down low. He was clean-shaven and wore a look of quiet determination. Hildebrand, on the other hand, looked like he’d just waltzed out of a rock concert, a little dazed but with his mind still full of music. His chin had the reddish beginnings of a beard — it would need to be covered before he started touching cows — and his coat was a thinning mosaic of patches. They’d come from his cousins and parents, the reject bin at Fabricland, the lady who runs the shawarma shop downtown: bits of leopard print and floral patterning, a horse and a mushroom and a jellyfish with metallic button eyes. They were both ready for a day of work.

The team had a pre-abattoir ritual of breakfast at Tim Horton’s — “just to make sure everybody is awake, talk about the day ahead, reminders about safety,” Taylor explained.

That day, they talked about the snow, about the slowness of plows. They talked about their colleague Abe — a housemate of Hildebrand’s, and now a surfactant extractor — who had just been bitten by a wild dog in Peru. “It was a very abrupt vacation,” Hildebrand said. “He had the idea and bought a ticket a week later.”

Taylor looked up from his muffin, which he was tearing into chunks. “I wish I were like that.”

“Your time will come,” said Meghan Smith, another worker. “You might be 70, but it’ll come.”

“Get the last kid out and off you go,” Hildebrand said.

The conversation drifted on to other things. They were to leave at 5:10, and Taylor was startled when he looked at his phone. “Oh, jeez, we gotta go,” he said. “It’s 13 past.”

Within 15 minutes, they’d skidded back past the hotel, past the University of Guelph, past the dump, and were stopped at the abattoir’s security shack. They waited for what seemed like a long time, as slaughterhouse employees zipped past, the moon hanging low over the barbed wire. Then they were in, setting up their equipment, tapping into the water supply, changing into rubber boots, gray button-downs, elastic-waistband pants, regulation earplugs. They brought their street clothes out to the truck.

At around 6:10, the first cows had been dispatched and were starting to come by, head down. The team was ready. One of them used a knife to poke into the trachea and make a vertical slit of about six or seven inches. Then came the hardest part: The next person had to push a tube up into the opening. It was a tight fit. “It feels like trying to put your foot in a shoe that’s two sizes too small,” Taylor said.

Doing it properly meant hooking two of the fingers on your left hand into the squishy bottom of the slit to get some purchase on the thing, and then maneuvering the tube with your right. There was a clamping mechanism to hold it in place, and then the extraction itself would begin, with 20 liters of salt water whooshing up into the lungs.

The water came flowing back down looking much as it had seconds before. The main difference was a head of foam floating on top, a few inches high. That was the stuff they were after. A single set of cow lungs usually provides enough to get two preemies breathing.

While someone was cutting and another person was inserting, a third was manning the machines. A fourth person was in charge of removing the tube. It was a flurry of movement, everything happening at once: tubes being sanitized in scalding hot water, slits being made, insertions, removals, adjustments to the machines. They had about 28 seconds for each cow, which didn’t leave much time to think.

Of the 1,500 or so head of cattle the facility deals with every day, the BLES team is usually able to get to around 700. If they didn’t break the foam down with solvents and machines, there would be enough to fill a good-sized room.

It was, as Nigh put it, “a good hard day’s work.” The hours and the repetition were exhausting, and even though they switched roles every 50 cows or so, they could feel the strain of tube-insertions in their shoulders, their wrists, and their ribs. “It’s kind of like a work hangover,” Taylor said.

That day, the truck pulled up outside their headquarters in London just as the winter dark was setting in. The tank that held the foam was remarkably small — it looked like a silver R2-D2 on wheels. It was hard to believe it contained ingredients enough to make medication for some 1,400 babies. Soon, the sky would be the same inky color it had been when they were waking up.

Good as bovine surfactant may be, you cannot just suck it out of a cow and squirt it straight down a preemie’s throat. The purification it undergoes is intense, a highly regulated kind of alchemy.

No matter how tired he is, Taylor likes to come watch the first steps of it, and he was back in the warehouse at 8:30 a.m., as two of his colleagues in turquoise lab coats and pink respirator masks wheeled R2-D2 toward the wall and inserted hooks into its handles. Slowly, with a mechanical groan, the tank was lifted up on chains.

The workers maneuvered a clear vessel into place underneath, jacked it up to the right height, unscrewed a valve at the bottom of R2-D2, inserted a white Teflon tube that connected the silver tank above to the clear jug below. And then there it was, a whitish-yellowish substance, like Maine clam chowder without the clams.

“That’s it, there you go, there’s just over 700 cows’ worth of product in there,” Taylor said. It looked about the same every week, but he always found the sight of it to be a relief.

Over the next few days, it would be centrifuged and dried down in rotary evaporators. Solvent would be added, and then it would be dried down again. It would go from milky white to a clarified golden brown — like maple syrup, but less viscous. As it got purified, it would turn into a waxy solid, and then be liquefied again. By the time it got to quality control for double-checking, it was baby-safe.

The whole business was relentlessly high-tech, with sterile equipment, workers in masks and full-body coveralls, but every step also involved the deep focus of a craft, perfected over thousands of repetitions, gestures passed from one person to another that you couldn’t learn by reading the patent.

There are chemists out there who are convinced it will all soon be obsolete, replaced by one synthetic or another, pulled under by the tide of biotech. But the extractors and the purifiers here didn’t seem worried.

The discussion seemed at once urgent and moot on that Thursday afternoon, in the NICU at the London Health Sciences Center, about a 20-minute drive from the lab where BLES was doing its purification. A neonatologist pulled back a rocket-ship blanket to show off a baby in the half-light of an isolette. He’d been born a few days before, at just over 26 weeks. He was a deep reddish-pink, and tiny, his chest fluttering with the rapid artificial breaths of a ventilator.

The parents sat by in pajamas, their faces covered in masks. They weren’t thinking about the abattoir that sat an hour and a half to the east. Nor could they know about the tinkerers and the lung-mincers, the theologians and the pine-cone-pickers, the chemists and their long obsession with synthetics.

You could still see the traces of the surfactant therapy the kid had gotten — a colorful tube that lay next to him on the bed. The respiratory therapist had taken a vial from the fridge with what looked like sour milk inside. He’d drawn the stuff up into a syringe, and gently rolled it in his hands to warm it. He’d attached the syringe to the end of a catheter, and nudged the tube down the baby’s throat. Then, counting one Mississippi, two Mississippi, three Mississippi, he’d pushed the foam as far as it would go into the lungs.