Learning about social determinants of health with California Surgeon General Dr. Nadine Burke-Harris
At Verily, we are always looking for ways to root our work back to our mission and to inspire our teams to holistically serve patients. To achieve these goals, Dr. Jessica Mega, Verily’s Chief Medical & Scientific Officer sat down with Dr. Nadine Burke Harris, California’s first Surgeon General and the physician credited with bringing the public health crisis of adverse childhood experiences (ACEs) to the forefront of the public eye.
Dr. Nadine Burke Harris’ career has been dedicated to serving vulnerable communities and combating the root causes of health disparities. In 2011, she founded the Center for Youth Wellness (CYW) and subsequently grew the organization to national leadership in the effort to advance pediatric medicine, raise public awareness, and transform the way society responds to children exposed to ACEs and toxic stress. While at CYW, she also championed the Bay Area Research Consortium on Toxic Stress and Health, to bolster research and deliver the first tool to investigate how childhood adversity affects children’s health. As California Surgeon General, she is an advisor to the Governor and a leading spokesperson in matters of public health.
A few weeks after Dr. Burke-Harris’ visit, The Story of Your Number, the first-ever public awareness campaign on ACEs and toxic stress, launched. The campaign aims to bring the research on ACEs out of the journals and into mainstream society. You can learn more at Numberstory.org.
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Q&A
Can you talk to us about the role that social determinants of health play and how they impact your work?
Social determinants of health are factors related to people’s environment or conditions that are shown to impact their health outcomes. In my role as California Surgeon General, line one on the job description is thinking with a public health approach and thinking about things by looking at their root causes. A lot of public health is thinking about how our environments shape our health.
In California, we use the Healthy Places Index where we will look at things like access to green space, housing density, or access to fresh foods and vegetables. When you have close housing density, less access to outdoor green spaces, or no option of working from home, we see that that translates directly into disease and death. When we think about how to deploy population health at scale, we have to be thinking about these social determinants, otherwise what we do will be ineffective.
The COVID-19 pandemic showcases the impact of how our conditions and environments (the places we live, learn, work, and play) impact our health. COVID-19 is a virus, spread from one person to another. And yet, in California our most socioeconomically advantaged segment of the population had experienced 10% of infection and death but received 36% of vaccines. As compared to our lowest segment that has experienced 40% of infection and death and received only 16% of vaccines. This is one example of social determinants of health and their impact on health outcomes.
Your second year as California’s Surgeon General brought incredible challenges with the COVID-19 pandemic. How has the pandemic shaped your approach?
The pandemic has impacted my role by being omnipresent, it’s all day everyday. Before the pandemic, my three big areas of focus included early childhood, health equity, and mitigating the impact of adverse childhood events (ACEs) and toxic stress.
Now as we plan safe school reopening, the work we have been doing related to ACEs and toxic stress went from being considered interesting to a must-have in every school district. Every district needs to know how to support kids because we know this pandemic has been a major stressor.
How do you define ACEs and what are the biggest opportunities to address them in a meaningful way?
The term ACEs comes from a landmark study between the CDC and Kaiser Perminante published over two decades ago. They looked across 10 categories of ACEs including physical social or sexual abuse, physical or emotional neglect, or growing up in an unstable household. According to this study, two thirds of the population has experienced one ACE. California state government’s own research shows 62% of Californians have experienced one ACE and 16% have experienced four or more. There was an association between adverse childhood experience and negative health outcomes, including 9 out of 10 of the leading causes of death in the United States.
Population data show having four or more ACEs more than doubles your risk for ischemic heart disease, the number one killer in the United States. Exposure to high doses of adversity, especially during those crucial developmental years, leads to a prolonged activation of biological stress response that can change the development of our brains, our immune system, and our hormones.
The good news is that a prolonged toxic stress response is treatable, if healthcare providers are trained on how to recognize it. Some evidence-based health interventions that are shown to regulate stress response are exercise and mindfulness.
During the pandemic, have you seen a shift of the ACEs that are being identified or do you think only time will tell?
The number one question I get these days is whether the pandemic is an ‘ACE’. While the pandemic itself may not fall within the traditional ACE criteria, we are seeing the rates of traditional ACE prevalences are increasing. For example, intimate partner violence and substance use are both on the rise during the pandemic. A study from the Kaiser Family Foundation on rates of anxiety and depression showed a 30% increase between June 2019 and January 2021.
We see traditional ACEs rising, we know other risk factors for toxic stress, like loss of a job, are rising. Toxic stress occurs when you have exposure to adversity, without an adequate buffering caregiving system. Life is stressful! Human beings are designed to deal with pressure with help from things like hugs from loved ones to release our oxytocin in your brain and body to help us shut off that stress response. On top of everything kids are out of school, so there aren’t options for an extended caregiving community like teachers or coaches that help fill those gaps in buffering care.
What we have is a perfect storm of ACEs rising, missing pieces to the buffering caregiving interventions, and then particularly for communities of color, experiences of raciscm or discrimination also causing toxic stress. The results? We are seeing the rise in ACE-associated health conditions and a lot of people are struggling right now.
Knowing that health technology is part of a changing landscape, what gets you most excited and where are you more cautious?
Because of the pandemic, mental health treatment is now much more widely available with technology. Therapists are in incredibly high demand and are all utilizing different telehealth platforms. The pandemic has also brought more awareness to social determinants, and shown the intersection between pandemic and racial justice. Generally speaking I’m an optimist but I think we have big challenges ahead of us. As a broader community, we have what it will take to overcome them and technology can help, but it will be hard work.
Women and people of color are underrepresented in the tech industry. To address this issue, philanthropic longer term plays like Girls Who Code or Black Girls Code were born. What are some examples of community investments that can help improve diversity and inclusion in the workplace?
Google.org was an early investor in my previous organization the Center for Youth Wellness and when we invest in our community based organizations, we invest in leaders. We need to invest in leaders of color and leaders from diverse backgrounds. When you have diverse experiences you get insights you may otherwise lack. For many years in my professional life, I kept the research and the data under an objective lens but increasingly in my public role I’ve had to speak more about my own experiences of being a child of someone who suffered from a serious chronic health condition. It gives me the ability to look into patient journeys and understand them empathetically. It’s important to do this inside the philanthropic arena, but that is just the tip of the iceberg. We need some truly systemic shifts as a country.
When I look at ACEs data or other reports of discrimination, these are massive scale challenges and it will not be solved in the non-profit world alone. We need to orient our core business practices with this in mind. We are all part of the solution when anti-racism becomes a core part of what we do. What Verily is doing by incorporating the ACEs work into your own development and understanding is just an example of the type of reorientation we need to start creating the seismic shift.
This past year has been a stressful time for everyone and we know there could be real implications of long term health issues caused by this increase in stress. Recently you shared with Vogue some of your tactics for managing stress throughout the pandemic. What has the last year meant for you and what have you done to manage stress?
One of my favorite phrases is, “Self-care is not selfish.” Part of the reason for that is I am someone with a big bold ambitious agenda. I want to cut ACEs and toxic stress in California in half within one generation. We launched the ACEs Aware Initiative in the midst of the pandemic, trained more than 17,000 healthcare providers, and launched grants for new approaches to address ACEs. At the same time, I know that making big changes requires sustained effort over time, so it’s important to avoid burnout. I remind myself and my team that it is better to do 80% for 5 years than 95% for one year. You get more done when the area under the curve is larger.
This has been such a hard year and self-care strategies like Zooms with girlfriends, hikes and snuggles with my kids, and mindfulness practices have never been more important. As much as I am incredibly ambitious, that ambition requires that I practice self-care so that I can be there in the long run to do the work.