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  • Could South Carolina Change Everything?

    Could South Carolina Change Everything?

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    For more than four decades, South Carolina has been the decisive contest in the Republican presidential primaries—the state most likely to anoint the GOP’s eventual nominee. On Saturday, South Carolina seems poised to play that role again.

    Since the state moved to its prominent early position on the GOP presidential-primary calendar in 1980, the candidate who has won there has captured the nomination in every contested race except one. Given Donald Trump’s overall lead in the GOP race, a victory for him in South Carolina over Nikki Haley, the state’s former governor, would likely uphold that streak.

    “We all underestimate how deeply ingrained the Trump message is in the rank and file of our party,” Warren Tompkins, a longtime South Carolina–based GOP strategist and lobbyist, told me. “Take the personality out of it: What he stands for, what he says he’ll do, and what he did as president; he’s on the money.”

    This year, though, there may be a twist in South Carolina’s usual role of confirming the eventual GOP winner: Even as the state demonstrates Trump’s strength in the primary, it may also spotlight his potential difficulties as a general-election nominee. Like the first contests in Iowa and New Hampshire, South Carolina may show that though most Republican voters are ready to renominate Trump, a substantial minority of the GOP coalition has grown disaffected from him. And in a general-election rematch, that could provide a crucial opening for President Joe Biden, despite all of his vulnerabilities, to attract some ordinarily Republican-leaning voters.

    “Trump is essentially the incumbent leader of the party who is not able to get higher than, say, 65 percent” in the primaries, Alex Stroman, a former executive director of the South Carolina Republican Party, told me.

    Local observers say Haley has run a textbook South Carolina campaign, barnstorming the state in a bus, appearing relentlessly on national television, spending heavily on television advertising, and notably intensifying her criticism of Trump as “unhinged” and “diminished.” Trump, meanwhile, has breezed through the state as quickly as a snowbird motoring down I-95 from New York to Florida for the winter. Yet he has retained an imposing lead reaching as high as two to one over Haley in the polls.

    “I think you can argue Haley is running a fantastic campaign” in South Carolina, Jordan Ragusa, a political scientist at the College of Charleston and a co-author of a history of the South Carolina primary, told me. “But the pool of available voters is just so small that no matter what she does, it’s going to be hard for her to move the needle.”

    Read: The GOP has crossed an ominous threshold on foreign policy

    Over the past generation, South Carolina has had an extraordinary impact in shaping the outcome of GOP presidential-nomination contests. The state moved near the front of the GOP primary calendar in 1980, when Republicans were just establishing themselves as a competitive force in the state. GOP leaders created the primary, with its unusual scheduling on a Saturday, as a way to generate more attention for the party, which had previously selected its delegates at a convention attended by party insiders.

    The other key factor in creating the primary was support from Ronald Reagan’s presidential campaign, including Lee Atwater, a prominent GOP strategist then based in South Carolina. South Carolina did what Atwater hoped when Reagan won it in a rout, after unexpectedly losing the Iowa caucus to George H. W. Bush.

    Reagan’s victory in South Carolina placed him back on the path for the GOP nomination and cut a mold that has endured, with only one exception, in every contested GOP presidential-primary race through 2016. Each of those races followed the same formula: One candidate won the Iowa caucus, a second candidate won the New Hampshire primary, and then one of those two won South Carolina and eventually captured the nomination. (The exception came in 2012, when a backlash to a debate question about his marriage propelled Newt Gingrich to a decisive South Carolina win over Mitt Romney, who recovered to claim the nomination.)

    In 2016, Trump’s narrow victory in South Carolina effectively cemented the nomination for him after he had lost Iowa to Senator Ted Cruz of Texas and then recovered to win in New Hampshire. A victory for Trump on Saturday would allow him to equal a feat achieved only by incumbent GOP presidents: sweeping Iowa, New Hampshire, and South Carolina.

    Three factors, above all, explain South Carolina’s enduring influence in the GOP race. One is that it reflects the overall Republican coalition better than either of the two states that precede it. In Iowa, the Republican electorate leans heavily toward evangelical Christians who prioritize social issues; in New Hampshire, where there are few evangelicals, economic conservatives focused on taxes and spending, as well as a sizable group of libertarian voters, have dominated. South Carolina is the synthesis of both: It has a large evangelical population and a substantial cohort of suburban, business-oriented Republicans outside its three principal population centers of Greenville, Columbia, and Charleston.

    “In a lot of ways, the state party here is a microcosm of the national party,” Jim Guth, a longtime political scientist at Furman University, in Greenville, told me. “We replicate the profile of the national party maybe better than New Hampshire [or] Iowa.”

    It has been possible for candidates over the years to win Iowa or New Hampshire primarily by mobilizing just one group, such as social conservatives in Iowa and moderate independents in New Hampshire. But because the South Carolina GOP contains so many different power centers, “you have to have a broader appeal,” Tompkins, who has worked in every GOP presidential primary since Reagan, told me.

    The second key factor in South Carolina’s importance has been its placement on the GOP calendar. From the outset, in 1980, the primary was designed by its sponsors as a “First in the South” contest that they hoped would signal to voters across the region which candidate had emerged as the favorite. As more southern states over the years concentrated their primaries on Super Tuesday, in early March, that multiplied the domino effect of winning the state.

    “Given the demographic alignment between South Carolina and a lot of the southern Super Tuesday states, and the momentum effect, it really made South Carolina pivotal,” Ragusa said.

    Read: Trump is about to steamroll Nikki Haley

    The third dynamic underpinning South Carolina’s influence has been its role as a fire wall against insurgent candidates such as John McCain in 2000 and Patrick J. Buchanan in the 1990s. South Carolina’s Republican leadership has usually coalesced predominantly behind the candidate with the most support from the national party establishment and then helped power them to victory in the state. That model wavered in 2012, when Gingrich won his upset victory, and even in 2016, when Trump won despite clear splits in the national GOP establishment about his candidacy. But most often, South Carolina has been an empire-strikes-back place where the establishment-backed front-runner in the race snuffs out the last flickers of viable opposition.

    All of these historic factors appear virtually certain to benefit Trump this year. Super Tuesday no longer revolves as much around southern states. But it remains a huge landscape: 15 states and American Samoa will all pick a combined 874 Republican delegates on March 5, nearly three-fourths of the total required to win the nomination.

    In the limited polling across the Super Tuesday states, Trump now leads, usually commandingly, in all of them. Haley has already announced campaign appearances in Super Tuesday states through next week. But with all of the Super Tuesday states voting just 10 days after South Carolina, it will be virtually impossible for Haley to close the gap in so many places at once without winning her home state or at least significantly exceeding expectations. Like earlier underdogs, she faces a stark equation: To change the race anywhere on Super Tuesday, she must change it everywhere through her showing in South Carolina.

    Saturday’s result could also reconfirm South Carolina’s other key historic roles. Trump is now the candidate of most of the GOP establishment—a dynamic reflected in his endorsement by virtually all of the leading Republicans in Haley’s home state. He’s also become the contender with the broadest appeal inside the Republican Party. Because Trump is so polarizing for the general public, it’s difficult to see him in that light. But South Carolina is likely to buttress the indications from Iowa and New Hampshire that Trump, as a quasi-incumbent, now has a broader reach across the Republican Party than Haley does, or, for that matter, than he himself did in 2016. In most South Carolina polls, Trump is now leading her with every major demographic group, except among the independents who plan to participate in the primary.

    Yet South Carolina, like Iowa and New Hampshire before it, will also provide important clues about the extent of the remaining resistance to Trump within the Republican coalition.

    Haley is likely to perform best among well-educated voters around the population centers of Columbia and Charleston. “Haley must run up the score with traditional Reagan Republicans who want to actually nominate a candidate who can win in the general election,” Stroman told me. “She is going to be absolutely swamped in the MAGA-rich right-wing upstate, and in rural areas across the state—so she needs the suburbs and cities to turn out to hopefully keep her closer than expected.”

    In New Hampshire, Haley finished closer to Trump than most polls projected, because a large number of independent voters, and even a slice of Democrats, turned out to support her.  She’ll need a similar dynamic to finish credibly in South Carolina, where she has said her goal is to exceed her 43 percent of the vote in New Hampshire. The better the showing for Haley among independents, and among college-educated voters in the suburbs, the stronger the general-election warning signs for Trump.

    Democratic voters could be a wild card on Saturday after relatively few of them turned out for the party’s own primary earlier this month. South Carolina does not have party registration, which means that any voter who did not participate in the Democratic primary can vote in the Republican contest. A group called Primary Pivot has launched a campaign to encourage Democrats and independents to swarm the GOP primary to weaken Trump. If Haley exceeds expectations in South Carolina, it will be because, as in New Hampshire, more independents and Democrats turn out for her than pollsters anticipated.

    Besting Trump for the nomination may no longer be a realistic goal for Haley if she loses her home state. But, after mostly dodging confrontation with Trump for months, she is now delivering a more cogent and caustic argument against him, and showing a determination to force Republicans to wrestle with the general-election risks they are accepting by renominating him. The biggest question in South Carolina may not be whether Haley can beat Trump, but whether the state provides her more evidence, even in defeat, to make that case.

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    Ronald Brownstein

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  • How a Common Stomach Bug Causes Cancer

    How a Common Stomach Bug Causes Cancer

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    At first, doctors didn’t believe that bacteria could live in the stomach at all. Too acidic, they thought. But in 1984, a young Australian physician named Barry Marshall gulped down an infamous concoction of beef broth laced with Helicobacter pylori bacteria. On day eight, he started vomiting. On day 10, an endoscopy revealed that H. pylori had colonized his stomach, their characteristic spiral shape unmistakeable under the microscope.

    Left untreated, H. pylori usually establishes infections that persist for an entire lifetime, and they’re common: Half of the world’s population harbors H. pylori inside their stomach, as do more than one in three Americans. In most cases, the microbe settles into an asymptomatic chronic infection, but in some, it becomes far more troublesome. It can, for example, cause enough damage to the stomach lining to create ulcers. Worse still, H. pylori can lead to cancer. This single bacterium is by far the No. 1 risk factor in stomach cancers worldwide. By one estimate, some 70 percent can be attributed to H. pylori.

    But what still puzzles doctors years later is why H. pylori has such different consequences for different people. Why is it asymptomatic in most but carcinogenic in others? Although the full answer is complex, one key factor seems to be mutations in H. pylori itself. Not every strain is created equal. The presence of select genes intensifies H. pylori’s pathogenicity, and even a single mutation in a single gene, scientists recently found, enhances the link to cancer. A small genetic tweak in a common stomach bug could have profound consequences for us, its unwitting hosts.

    H. pylori has lived inside of us for a long time. Our ancestors who left Africa likely carried it inside them as they crossed continents and oceans, built and felled civilizations. And over the course of what some scientists hypothesize to be more than 100,000 years of co-evolution, H. pylori has exquisitely adapted to the harsh, acidic conditions of the human stomach.

    It survives, for example, by producing “copious amounts” of an enzyme that neutralizes stomach acid, Richard Peek, a gastroenterologist at Vanderbilt, told me. H. pylori can also burrow into the mucus-gel lining of the stomach using powerful, whiplike flagella. The mucus lining offers a relative haven from stomach acid, but another prize lies underneath too: stomach cells, rich in nutrients that the bacteria needs to survive.

    The way that H. pylori steals nutrients could be the key to how it ends up causing cancer. The bacterium isn’t necessarily out to hurt its human host. “H. pylori doesn’t want you to get an ulcer or to get cancer, but it needs to replicate to high enough levels in the stomach that it can be transmitted to another person,” Nina Salama, a biologist at Fred Hutchinson Cancer Center, told me. (The bacteria seem to spread through an infected person’s saliva, vomit, or feces.) But to replicate, it needs nutrients, in particular iron, which our cells probably hoard to starve pathogens.

    In response, certain strains of H. pylori have evolved genetic changes that might make its iron-mining more efficient. But this also causes more collateral damage to the host’s stomach, enough damage, perhaps, to eventually trigger cancer. First, the bacteria uses a protein called HtrA—essentially “a pair of molecular scissors,” Peek said—to cut the bonds that hold stomach cells together, so the microbes can slip between. A single mutation in this scissor protein makes it better at cutting, a group based in Germany found in a recent study, and this mutation is disproportionately found in H. pylori strains isolated from people who developed stomach cancer.

    Once H. pylori has wedged itself in between cells, it also has clever ways of accessing the nutrients inside. Certain strains carry a set of about 18 genes that collectively encode a molecular needle through which H. pylori injects bacterial proteins, triggering a cascade of changes to the cell. These hijacked cells end up giving up their iron more easily, but they also become worse at essential functions such as fixing damaged DNA. This set of approximately 18 genes, collectively called the “cag pathogenicity island,” are in fact disproportionately found in strains from cancer patients. Stomach cancer thus might be a secondary consequence of the microbe’s aggressive search for nutrients. For the H. pylori, “there’s no selective pressure to cause cancer in 80 years. The selective pressure is to acquire iron now,” Karen Guillemin, a microbiologist at the University of Oregon, said.

    But not everyone infected with one of these cancer-linked strains will develop cancer. Other factors likely play a role too: diet, environment, and genetics of the individual patient  Stomach-cancer rates vary quite widely around the world, with the highest prevalence in East Asia. In Japan, doctors routinely test for H. pylori in people with no symptoms, and prescribe antibiotics if the tests come back positive. But some scientists have argued against aggressive treatment, pointing at hints that humans derive some benefits from living with H. pylori too. Those infected, for example, tend to have lower rates of asthma and allergy. Genetic signatures associated with more pathogenic H. pylori strains, Peek told me, would help identify those at highest risk, who could most benefit from antibiotics.

    Marshall, the Australian doctor who infected himself with H. pylori, ultimately recovered just fine. His self-experiment, in addition to other studies with his collaborator Robin Warren, proved that the bacterium does indeed infect the stomach and does indeed cause stomach ulcers, which later spurred the work linking H. pylori to cancer. Understanding exactly how and why H. pylori becomes pathogenic is still key to finding the way to treat it, but in the past 40 years the significance of H. pylori to human health has become indisputable—so much so that in 2005, Marshall and Warren won the Nobel Prize in Medicine.

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    Sarah Zhang

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