Applying the Science of Toxic Stress to Transform Outcomes in California
12
March

By Adem Lewis / in , , , , , /


(upbeat music) – Good morning. – [Audience] Good morning. – I’m very excited
about welcoming everyone to the 2020 Chancellor’s
Health Policy Lecture. I’m Claire Brindis, and I’m the Director of the Philip R. Lee Institute
for Health Policy Studies. And I’d just like to take
a couple minutes explaining what the Chancellor’s
Health Policy Lecture is and introduce to you
our current chancellor, Sam Hawgood, and give you
a little bit of background. But most of our time today will be devoted to a very special guest. The Chancellor’s Health Policy Lecturer was established in 2006 by
then Chancellor Mike Bishop with the tremendous
encouragement and support of a very dear friend, Steve Schroeder. And the purpose of the
lecture is to really bring star health policy leaders to our campus in recognition of the very important role that health policy plays in
establishing the landscape, establishing the environment
in which we conduct our work. And because so many of you
are involved in research, in training, in clinical
care, in community service that shapes policy in
California, in our nation, and in the world, it’s also
an opportunity to celebrate the role of health policy in our lives. And I wanna acknowledge
the wonderful support of the Student Leadership Forum Group on Diversity and Inclusion who will be meeting in
this room right at the end and the conclusion of this lecture. So I’m gonna ask that we
respect their time here and we will be leaving promptly. For me personally, it is really an honor to give a little bit of
background on our own Chancellor Sam Hawgood. Sam brings a particular
sensitivity to the importance of policy both in his
own professional work and in his leadership
skills and responsibilities. And I wanna acknowledge
that he began his career at UCSF in 1982 as a research fellow. And the work that he conducted in terms of low infant born
babies with pulmonary problems contributed to massive changes
in the way that we deliver health care to our most
vulnerable citizens and have probably saved the lives of millions of people around the globe. It was this kind of work
that helped to generate his career at UCSF, and
I would hazard to guess that there are people in this room who have probably benefited
from Sam’s instrumental and groundbreaking research. His leadership at UCSF has included being a division lead in the Department of Pediatrics, the Chair of Pediatrics, then dean, and then becoming the chancellor. Under his leadership,
the school has really grown substantially, partly
because of his vision and his leadership style
that is very inclusive. And we are really one of the
topmost research institutions recognized both in terms
of our NIH funding, but also the contributions
that many of you make in the policy, research,
training, and service arenas. And I wanna just thank Sam for having been such a wonderful leader, and
welcome him to the stage. (audience applauding) – Thank you, Claire, for those embarrassingly generous remarks. But it is indeed a real
honor for me to be here today and to look out on this audience, many of you who are helping
shape the future of, as Claire said, not only
our city, but our state, our country, and the world. I would like also to right at the outset thank Claire for your
remarkable leadership over the Health Policy
Institute for so many years and the way that you and your
team continue to shine a light on the importance of health policy and the role that health
policy has in driving true transformational change
at all levels of health care throughout the country. 2020, it’s a little hard to
say but we are at the start of a new decade, but
clearly still in a point of political uncertainty in this country. And I think that uncertainty
continues to underscore the critical importance of
getting health policy right, policy that can last
beyond any given political leadership or regime. And good policy doesn’t
just come out of thin air. It comes from very hard
work, analytic work, continual review of outcomes. And it’s that kind of
work that our Institute for Health Policy does here at UCSF. It underscores the commitment
across the entirety of UCSF to the health and well-being
of our own community. And by community, I not
only define our community here in the Bay Area, but our community across the state of California, our community across
the country of the U.S., and our community in our
global health efforts. I’m very optimistic as I look out to this room this morning,
and for those that I know will follow this online
who can’t be with us today. It gives me great optimism
that the contributions of all of you will have profound impact on our ongoing struggles to
affect health disparities amongst the most vulnerable
populations that we serve. Through the efforts of many
of you and others at UCSF at times clash with political sentiments, it’s our strength as a
university that stems from the culture that embraces
these kind of challenges. We all work together, as I like to say, to tackle the globe’s biggest
and most difficult problems. And so, it’s within that
spirit that it gives me great pleasure to introduce
the 2020 Chancellor’s Lecturer on Public Policy. And that is Dr. Nadine Burke Harris. (audience applauding) Dr. Burke Harris is an
award-winning physician, researcher, and advocate
who has dedicated her career to changing the way our society responds to one of the most serious,
pervasive, expensive, and widespread public
health crises of our time. That is childhood trauma. She was appointed, as
I’m sure all of you know, as California’s first ever Surgeon General by Governor Gavin Newsom in January 2019. Her career has been dedicated to serving the most vulnerable communities and combating the root
causes of health disparities. We at UCSF have already
had great opportunities to work closely with Dr. Harris. And I’m sure that this
lecture will once again be just the start of wonderful things that we can do together. And Nadine, I pledge that
UCSF will do everything we can to make your tenure as our
very first Surgeon General a roaring success. So please join me in welcoming Dr. Burke Harris to the podium. (audience applauding) – Thank you so much. It’s such a privilege and an
honor to have the opportunity to speak to you this morning. And I’m excited to jump
into this conversation about applying the science of toxic stress to transform health
outcomes in California. In February of last year, it was actually February 11, 2019, when I was sworn in by the governor as California’s first Surgeon General. And in the governor’s executive
order creating the role of California Surgeon
General, one of the things that he did was recognize the early adversity and recognize social
determinants of health as root causes of some of the most severe, intractable, and expensive challenges that are facing California today. And that was the reason
why he created the role of state Surgeon General. Specifically, he charged me to go upstream and address those root causes in a way that is systemic and sustainable. And together, we identified for the Office of the Surgeon
General three key priorities that I really wanted to work on which include health
equity, early childhood, and adverse childhood
experiences and toxic stress. Now, I don’t know where y’all
were on November 5, 2019, but I can tell you where I was. At six a.m., I was in the
Citizen Hotel in Sacramento when in came my email. Adverse childhood
experiences were on the cover of the MMWR, the Morbidity
and Mortality Weekly Report. (audience applauding) Now I know that many of
you in the room, like me, are public health nerds, right. And so, cover of MMWR is
like cover of Vogue, right. (audience laughing) This was like, I literally was like jumping up and down and screaming. And the reason was because
when the CDC issued a special issue of the Morbidity
and Mortality Weekly Report recognizing adverse childhood experiences as a major public health threat, that was such a powerful
signal, nationally. I feel like it was our
moment of breaking through. It was such a powerful signal nationally about the importance of
this work and this research and really adversity
as a major risk factor for health and disease. And as I jump into talking a little bit about California’s approach to addressing adverse childhood experiences, I wanna start by recognizing that we’re talking about childhood adversity. And so, when we’re talking about ACEs, we’re not talking about
that other auditorium with those other folks. For a lot of us, we’re talking
about many of us in this room who have had these experiences. So before I jump into this,
I just wanna recognize that if anyone needs to take a moment or excuse themselves,
please, that’s what we want folks to do what they need
to support themselves. But when we talk about
adverse childhood experiences, in reviewing the traditional criteria, as I look around the
room, I know many of folks are familiar with ACEs. But just as a reminder that
when we talk about ACEs, we’re referring to the
criteria from the ACE Study, and those include the 10 criteria including physical,
emotional, and sexual abuse; physical and emotional neglect; and growing up in a
household where a parent was mentally ill, substance dependent, incarcerated where there
was parental separation; or divorce; or domestic violence. So these are the 10
traditional ACE criteria. We recognize that there
are other adversities that are not included in that:
things like discrimination, being separated from
your parent or caregiver through deportation and migration. There are lots of other adversities that weren’t necessarily included. But when we look at the data, when we say for an individual who
has four or more ACEs their relative risk of
a health condition is X, it’s really important that we
are comparing apples to apples and oranges to oranges, and being clear when we’re talking about the traditional ACE criteria
versus other risk factors for long-term negative health outcomes. But what the ACE Study told us was two really really powerful things. And I feel like I’m here
at UCSF, I’m looking, I feel like I’m preaching to the choir. So you all could be telling
me this information. But the first really important
thing that it told us was that ACEs are incredibly common. So this doesn’t just happen
in certain zip codes, or to certain folks. But when we look here in California, 62.7% of Californians have experienced at least one adverse childhood experience. And 17.6% of Californians have experienced four or more ACEs. And that really defied common
wisdom I think for many, that these things only
happen in certain places or to certain people. But the other piece of it
that was really powerful is that the original
ACE Study was conducted in a community that was 70%
Caucasian, 70% college educated. So really, this is all of us. And when we look at the
traditional ACEs data, the most recent data for which we have at least some data around
racial and ethnic data, what we see is that in California, the prevalence of ACEs
across different racial and ethnic groups is
actually really similar, with our Hispanic and Latino communities reporting the highest rate of ACEs, and our Asian American communities reporting the lowest rates. We also see that, as it’s not surprising, when we look nationally
at the prevalence of ACEs, among those with moderate to upper income, the prevalence is very similar: that what they saw in
the ACE Study was 13.2% of individuals having four or more ACEs. But among individuals who are low income or in poverty, that number doubled. So we really see this profound effect of those who are low income
being at greater risk. So the first thing that
we understood was that ACEs are really common. They affect all
communities, but they affect communities in poverty more severely. The second thing that
they found in the study was that there was a
dose-response relationship between these adverse
childhood experiences and not just the stuff that we kind of commonly associate with
having a rough childhood: increased risk of mental
or behavioral disorders or increased risk of substance dependence, and we do see that strong association. But we see this dramatically
increased risk for things like heart disease and
cancer and autoimmune disease. And in fact, here we have a list of the 10 leading causes of death
in the United States. And over the past two decades since the ACE Study was published, what we’ve identified was that
ACEs dramatically increase the risk for nine out of 10
of the leading causes of death in the U.S. Similarly, we also see,
we do see some of those kind of expected or more commonly known dose-response relationships between adverse childhood experiences and negative mental health outcomes. Substance use, homelessness, when we look here in
California as I’m working with my colleagues across
the Newsom administration to grapple with and respond
to the homelessness crisis, what we see is that there is this profound dose-response relationship
between ACEs and homelessness. And so, when we look at
all of these associations, it’s really easy to feel
like it’s gloom and doom, like oh my goodness, you
have ACEs and it’s so rough and it just feels like you’re destined to have terrible outcomes. But for me, anyone who
knows me really well will tell you that one of
my favorite things to do is to try to figure out
how to take a weakness and turn it into a strength. So this list, when we look at homelessness and recognizing that’s such a big crisis and it’s such a big priority
for the administration. We see mental health
as such a big priority for the administration. That list of the nine out of
10 leading causes of death, they’re expensive. And so, one of the things
that’s been absolutely critical for me is recognizing that
addressing ACEs is not just a moral imperative and
an ethical imperative, it’s also an economic imperative. And the more that we recognize that, the clearer it is that
we can no longer afford not to put the resources in
place to address this issue in a systematic way. I wanna say last week, two weeks ago, there was a study published
that the annual cost of ACEs to the state of California for just these eight health conditions, this doesn’t include the
cost of incarceration, this doesn’t include the cost
to our educational system, for just these eight health conditions, is 112.5 billion dollars per year. That’s over a trillion
dollars in the next decade. We do not have an option other than to tackle this challenge head on. Because you wanna know what? You wanna know what the good news is? The good news is that
ACEs are not destiny. And what the research shows us is that with early detection and
evidence-based intervention, we can transform health outcomes. But in order to do that, we have to understand the mechanism. We need to have that blueprint to better understand what are the levers that are going to improve these outcomes. As surgeon general, one
of the things that I do is look back at other models
of how we have effectively disrupted major public health challenges. And a great example is HIV/AIDS. So back in the early 80s,
I’m looking around the room, there’s enough people here who
were around in the early 80s. I myself was in elementary school. (audience laughing) But you know, anyways. Back in the early 80s, doctors were seeing patients come into the emergency room with these surprisingly
high rates of tuberculosis. And doctors said, “Oh TB,
I know how to treat that.” Write the prescription; send ’em out. And then, they were coming in
with surprisingly high rates of this weird pneumonia,
pneumocystic pneumonia. Doctors said, “Gosh,
pneumocystis, I don’t see that “all that often, but I
know I can look it up.” Look up the treatment,
take care of the patient, send ’em home. And then, patients were coming in with these rare skin
lesions, so Kaposi’s sarcoma. Doctors said, “You know
what, I know I don’t know “how to treat that ’cause
this is really uncommon. “But guess what, I have a
colleague who does know. “So I’m gonna refer you to my colleague. “He’s gonna patch you up
and gonna send you out.” And what happened? Patients kept on coming back. And when they came back, they were sicker and sicker and sicker. So much so in fact that it
was on the cover of the MMWR, the Morbidity and Mortality Weekly Report back in I believe it was 1980, 1981. And we sounded the alarm on
this public health crisis. And we began to look systematically to better understand what was going on. And we figured out: oh my
goodness, you know what, it’s a virus. It’s not just a virus, it’s a retrovirus. And through the collaborative
efforts of researchers across the country, we were
able to develop antiretrovirals. And when we put that treatment into place, what we saw was that the death
rate from HIV/AIDS plummeted. Mean mortality went from six months: 50% of people were dead
six months from diagnosis to now on standard antiretroviral therapy, the life expectancy is greater
than 50 years from diagnosis. Ladies and gentlemen,
we did that in 30 years. And I wanna point out
something which is my absolute favorite part of this slide,
that top line in the blue, that’s the death rate for
African American males. That second line in the
red is the death rate for Hispanic and Latino males. And many people probably
didn’t think about researchers developing antiretrovirals
as a tool for health equity. We also don’t think
about biomedical research as a tool for health equity. But when you have a condition that disproportionately harms those
who are most marginalized that when you develop
effective interventions, we see that these marginalized communities are the ones who stand
the most to benefit. So taking that framework and that approach when we look to understand
the biology of adversity, understanding these biological mechanisms so we can better understand how ACEs put us at increased risk
for morbidity and mortality, for negative health and social outcomes, we can use that knowledge
to disrupt those processes and improve outcomes. And I see a bunch of
familiar faces in the room. So ladies and gentlemen,
if you know this part, just go ahead and sing along. All right. (audience laughing) So how does it work? So you imagine, you’re
walking in the forest. So this all boils down to our biological fight-or-flight response. And it works a little something like this. You’re walking in the
forest and you see this guy. What happens in our brains and bodies? First of all, did I scare
you even a little bit? (audience laughing) Not too bad, but just
enough so you might be like: “Oh okay, I get it.” But what happens? Immediately, our amygdala,
the brain’s fear center, sounds the alarm and activates the release of stress hormones including
adrenaline and cortisol. So our hearts (thumping
sound) start to pound. Our pupils dilate. Our airways open up. We shunt blood to our
large skeletal muscles for running and jumping and away from that itty bitty muscle that
holds your bladder close. So you might pee your pants. No judgment, right. So you’re ready, you’re ready
to either fight that bear or run from the bear. But if you were to think
about it, fighting a bear wouldn’t seem like a good idea, would it? No, look at him. He’s big; he’s got teeth; he’s got claws. And that’s why our
amygdala sends projections to the prefrontal cortex,
the part that’s responsible for judgment and impulse control
and executive functioning, and turns it way way down. Because if you’re in a
forest and there is a bear, the last thing you want is impulse control getting in the way of survival. And instead, what it does is it turns up the part of the brain called
the noradrenergic nucleus of the locus coeruleus,
or as I like to call it the part of the brain responsible for I don’t know karate, but I do know karazy. (audience laughing) Thank you, James Brown. (audience laughing) So this is the part that gets us amped up. And the less obvious thing that happens when you activate your
stress response is that it also activates your immune response. Because if that bear
gets its claws into you, you want your immune system to be primed to bring inflammation,
to stabilize that wound so that you can live long enough to either beat that bear or get away. It’s brilliant. It was evolved over
millennia to save our lives from a mortal threat. But the problem is what
happens when that bear comes home every night. And this biological response is activated over and over and over again. And it goes from being
life-saving or adaptive to being maladaptive or health damaging. And children are especially vulnerable to this repeated activation
of the stress response because their brains and
bodies are just developing. So high doses of adversity in childhood are associated with
changes to the structure and function of children’s
developing brains; their developing immune
systems, hormonal systems; and even the way their DNA
is read and transcribed. And these long-term changes to the brain and biological system is what is now known as the toxic stress response. So when the ACE Study
was originally published, folks said, “Hey,
listen, this information, “it’s great to know,
but what do you want us “to do with this?” Because you have ACEs and it may increase your risk of heart disease; but by the time you
have the heart disease, there’s nothing that you
can do about the ACEs that you had in the past. Like, what are we
supposed to do with this? Well, there are a couple of things. Number one is that we now understand in the two decades since the
ACE Study has been published that the signs and
symptoms of toxic stress are evident as early as infancy. So in babies, we see increased
risk of developmental delay, growth delay, failure to
thrive, sleep disruption. And then as kids get older,
we see a litany of symptoms from increased risk of asthma, pneumonia, viral infections, moving
all the way to headache and abdominal pain, increased
risk of teen pregnancy, autoimmune disorders, et cetera. And as folks get older,
what we recognize is that biological toxic stress response, I used to wonder, I get it
these things happened to you when you were a kid. You had this overactive stress response, but then by the time
you get to be an adult, you’ve long since left that household. So why would you have
this continued activation of the stress response? And this is where this
genetic regulatory component comes in, because what we see is not only changes to the way our
stress response is wired, so that changes to the way our stress responsivity is long term. But we also see increased vulnerability to subsequent stressors
over the life course. And this toxic stress response, we even see that individuals, for example, women who had high ACEs
who become pregnant have increased risk of negative prenatal and perinatal outcomes. And their offspring also have increased stress sensitivity and vulnerability. But, and what is so powerful, when we now understand
that this is the mechanism, we can use the science to break the cycle. Because just as we talk
about the activation of the stress response, just as our bodies evolved this biological stress response to save our lives from a mortal threat, our bodies similarly evolved
physiologic mechanisms to regulate or counterbalance
the stress response. And what we see and what
the research shows us is that the characterization
of the toxic stress response is actually only one end of the spectrum. We recognize that the stress response is characterized in three ways. Positive stress response, that’s what’s saving you from the bear. And let’s all remember,
the folks who didn’t evolve the stress response, they didn’t live long enough to reproduce. (audience laughing) So the positive stress response. And then, the tolerable
stress response occurs when the stressor is more severe, more prolonged, more intense. But this little yellow
box here was so important that I highlighted it in yellow, and I’ll take a second to read it. Homeostasis, the body’s
biological balance, recovers through the buffering
effect of a caring adult or other interventions. I’m gonna repeat that. Homeostasis recovers
through the buffering effect of a caring adult or other interventions. And that actually, it
only moves into being this toxic stress response when we don’t have adequate buffering. And what we see is that these measures of our biological ability
to recover from adversity and counteract that
biological stress response, that also can be tracked
and measured in the science. In fact, MRI studies found
that institutionalized children who were randomized into high
quality nurturant caregiving, and I’m not gonna comment on how sad it is that kids have to be randomized into high quality nurturant caregiving. But in any case, when these
kids were randomized at age two into a nurturant caregiving environment, their MRI studies at age
eight showed normalization of the developmental trajectory of the white matter
structures in their brains. We see interventions like meditation being associated with
decreased inflammatory markers, and that social support protected
against the infection risk associated with increased
frequency of conflict. We see that oxytocin, this is my favorite hormone I will say; this is really really fascinating. I’m gonna say this as a mom, and my husband and I have four boys, and I know there’s
probably a lot of parents in the audience. What happens when our kids experience something frightening
or scary or terrible, and I don’t know that there is a household across the world that is
ever spared from scary or stressful things happening
to or in front of children. But when that happens, as
a mom, what’s my instinct? What do I do automatically? I scoop up my boys and I hug
’em up and I love ’em up, and I tell ’em: “You’re
okay and you are safe.” And what that does is
that it releases oxytocin in their brains and bodies. And it turns out oxytocin,
this is the bossest hormone, it inhibits the stress
response; it enhances bonding; it protects against
stress-induced cell death. It has antiinflammatory effects. It enhances metabolic homeostasis. And it protects the vascular endothelium, the lining on the inside of our arteries. So we see that our body
is wired to have these healing and protective mechanisms. And we see that these aspects
of nurturant caregiving, y’all just a quick show of hands. How many folks are familiar with the Michael Meaney study on the rat pups? A good number. Well, I’m just gonna tell the story anyway ’cause it’s one of my favorite stories. So Michael Meaney, McGill University, he’s a stress physiology researcher. He has these rat pups and he takes the rat babies after they’re born and he has a research
assistant stress ’em out: handles them, mess around with them, and then he gives them back to their moms. And some of the moms instinctively did lots of nurturant caregiving,
“Oh my baby, I’m so sorry “that horrible man was
handling you like that,” and did lots of licking
and grooming and nurturing. And some moms, um, not so much. And what Meaney and
his team found was that the offspring of the moms who
did lots of nurturant care, guess what, they performed
better on cognitive tests. They had a more normally
functioning stress response that turned itself off after
a stressor more normally. And when they themselves became parents, they became high nurturant parents. And what they looked at, they said, “What is this associated with?” And they found that the regulation was not in the genetic code, but it
was actually in the epigenome, the markers that sit on top of our DNA that regulates which parts of
our DNA are expressed or not. And then, I have a sneaking
suspicion that maybe Dr. Meaney has a penchant
for Lifetime television. I don’t know, right. But he did a crazy thing. He and his team did a crazy thing. With the next generation, they
switched the pups at birth. And so, the pups that were biologically from the low nurturing moms, they put ’em with a high
nurturing foster mom. And they repeated the same experiment. And the foster mom did the same thing, “Oh I’m so sorry; oh honey,”
lots of nurturant caregiving. And guess what happened? Those pups who were raised
by a high nurturing mom, they performed better on cognitive tests. They had a more normally
functioning stress response. They in the next generation
became more nurturant parents. And their epigenetic markers
modeled their foster mom, not their biological mom. When we are talking about the
power of nurturant caregiving, we are talking about the
power to change our biology down to our DNA. And what we looked at, my team
at my former organization, The Center for Youth Wellness, we looked at thousands and
thousands and thousands, about 20,000 studies. We kind of summarized the
literature into like six fast and easy steps that we
can all implement at home. And those are sleep, exercise, nutrition, mindfulness, mental health,
and healthy relationships. All of these interventions
reduce stress hormones, reduce inflammation,
enhance neuroplasticity, and are associated with
improved epigenetic regulation. And when we are talking about
the impact of nurturant care, this is not just an academic exercise. A group in Wales looked at the impact of nurturant caregiving
on health outcomes, and specifically they looked
at health protective behavior like fruits and vegetable consumption. They looked at health harming behaviors. And they also looked at mental well-being. Let me just take a quick second. This is a little complicated slide, but I’m just gonna take a
second to walk you through it. The solid bars are without
nurturant caregiving. The hatched bars are with
nurturant caregiving. So let’s just point to
this one right here. And the red is high ACEs, and the gray is no ACEs. So you’ll see starting over on the side, if you got high ACEs and
no nurturant caregiving, those are the worst outcomes. If you have high ACEs and you have lots of nurturant
caregiving, you can reduce the negative health
impacts by more than half. In fact, for many of these outcomes, you’ll see that the high ACEs,
high nurturant caregiving health impacts were almost the same as the no ACEs no nurturant caregiving. Very very close. And, of course, the
best off are the no ACEs high nurturant caregiving. So across the studies, what
we see is that regardless of the presence of ACEs,
buffering care is associated with better outcomes full stop. However, a particular study in Wales said for those with four or more ACEs, the presence of all of
the buffering care assets reduced the prevalence of
total childhood poor health: including asthma, allergies,
headache, digestive disorders, and school absenteeism
from 59.8% to 21.3%. Let me tell you, if there was a drug that could reduce the prevalence of negative health outcomes
from 59.8% to 21.3%, I would wanna have some
shares in that drug. This is powerful. We have the power to transform outcomes for the next generation. And so, coming into my role as California’s first Surgeon General, I have set a bold goal: to cut ACEs and toxic stress
in half in one generation. (audience applauding) And I know that sounds ambitious. And at the risk of being
laughed out of the room, I will tell you folks I
did not come into this job to do things by half measures and believe that we can’t get things done. I am here to go big or go home, and particularly because,
ladies and gentlemen, we have done it before. When we look at the
prevalence of cigarette use, smoking by teens, the prevalence went from 25% 25% in 2001 ish to 3.6% by the end of the 20 teens. Ladies and gentlemen, we
did that in two decades. But more specifically, when
we look here in California at our maternal mortality rate, California maternal mortality was reduced by 55% between 2006 and 2014 through a concerted initiative called the California Maternal
Quality Care Collaborative where we explicitly put into
place across the 200 hospitals where 98% of the births
in California take place, we explicitly put into
place clinical protocols tracking and addressing the major drivers of maternal mortality. And we achieved that 55%
reduction in maternal mortality here in California while
nationally maternal mortality continued to rise, which is the red bar. We can do this. And we do this by looking at the evidence, and we do this by systematically deploying all of the resources
that are at our disposal. And what the evidence shows
us is that number one, we have to intervene early. The National Academies
of Sciences, Engineering, and Medicine last July issued their Vibrant and Healthy Kids report. I know y’all read all 500
and umpteen pages of it. I’m sure it’s on your nightstand like it is on my nightstand. But what it tells us is that the preconception through
early life periods are foundational for healthy development across the life course. And biologically, a
number of critical systems are developing. And humans have high plasticity
during these life stages. So early detection and early intervention is absolutely critical. It also tells us that we have to address the systemic and structural factors. Because individual
experiences within systems vary dramatically based
on racial, cultural, and other personal characteristics. And while the effects of
these systemic factors are by no means deterministic,
they do help to set the odds. And when different odds
play out over time, they systematically generate
different health outcomes. So a health equity
approach requires systems to change in ways that
improve opportunities for good experiences and reduce the odds of adverse exposure. And what the National Academies did was laid out this important
conceptual framework where in the middle, in that dark blue right there’s the
biological, psychological, and socio-behavioral development, a lot of the biological
mechanisms of toxic stress that I have been talking
about earlier in my talk. But we recognize that what shapes our biological environment, what shapes whether that inflammation, the hormonal release,
that buffering response are family cohesion, social connections, and caregiver well-being to support healthy child development. And what shapes a caregiver’s
ability to be well and shape their child’s development? Well, healthy living conditions,
early care and education, our health care system. And what shapes all of that
are structural inequities in our socioeconomic and political driver. And in the Newsom
administration, I promise you right now we have folks who
are working on all fronts to drive towards health and health equity to the extent possible;
to shape, to infuse every aspect of each of these drivers with factors that drive
towards health and well-being. And one of the key
parts of that initiative is something that I’m really
really proud to be leading. Because as we also saw from
the National Academies’ report, there was a recommendation
to adopt and implement screening for trauma and
adversities early in life to increase the likelihood
of early detection, and an acknowledgement
that this has to include creating rapid response
and referral systems that can quickly bring
protective resources to bear when early-life adversities are detected through coordinated
cross-sector expertise. So California’s approach is number one, to establish primary prevention by addressing the systemic
and structural factors and deploying a coordinated
public education campaign; to systematically deploy
broad scale screening for average childhood experiences
to enable early detection and early intervention
of ACEs and toxic stress; to interrupt vertical transmission of ACEs by advancing screening
not only in children, but also in adults with special focus on the prenatal and early parenting years; to coordinate and strengthen
our network of referral and treatment systems to
make them more effective, accountable, and easy to navigate for children, adults, and providers; and to advance the science of toxic stress and identify potential
therapeutic targets. We need to deploy every, I’m
waiting for the antiretrovirals for the toxic stress response, right. And to improve the efficacy
of our interventions. And when we look, we recognize that these are all part of a larger picture: the biomedical research, the primary care screening and response, trauma-informed clinical care, our coordination of our county
and local networks of care, cross-sector training and competency, and public awareness. And Governor Newsom in
a historic investment has dedicated more than
160 million dollars over the course of the next three years to reimburse providers for screening, for once it’s not an unfunded mandate, and then also invest in
training providers how to screen and how to respond with
trauma-informed care. We’ve also allocated nine million dollars to the California Initiative
to Advance Precision Medicine to use precision medicine
approaches to identifying ACEs and toxic stress and
effective intervention. And we’re also in the coming budget year, fingers crossed, knock on wood, hoping for an additional
10 million dollars for cross-sector training
in the early childhood government workers, education,
and law enforcement sectors so that all of our response systems are trauma-informed and ACEs aware. The ACEs Aware Initiative
is this initiative that we have deployed to be able to address ACEs and toxic
stress across providers. It includes training, clinical
protocols, and payment. Our clinical tools are available on the website acesaware.org. And I’ll give just a quick highlight of what those clinical tools look like. But all of this I’ll say is
available on the website. And I’ll go very quickly as I recognize that timing is running short. So our adult screening
tool looks like this. There are two versions. It lists the 10 traditional ACEs. And this is the de-identified
version in which providers ask their patients
not to say which ACEs that they have experienced,
but only how many. There’s also an identified version where patients can say which
ones that they’ve experienced. I will say based on my own experience as co-investigator for the PEARLS Study on which some of this research is based, and I see my two
co-investigators: shout out, we recognize that actually
the de-identified version, in unpublished data so don’t be mad at me, but the de-identified
version actually facilitated greater patient comfort
and greater disclosure. So we have the adult screening tool. The pediatric screening tool also includes the 10 traditional ACEs,
and then separately includes other social
determinants of health that we recognize to also be risk factors for the toxic stress response. We’ve included a simple clinical workflow that primary care providers can refer to just like we do clinical
algorithms for anything else in primary care, and also an adverse childhood experiences and toxic stress risk assessment algorithm to help providers understand
whether their patient is at low risk, intermediate risk, or high risk of a toxic stress response. Because, again, the focus
is we screen for ACEs at the most expedient
and evidence-based way of understanding which
patients are at risk of having a toxic stress response. But what we wanna be treating is that biology of toxic stress. And we do that by
providing patient education abut toxic stress, it’s likely role in the patient’s health
condition, and resilience. We assess for protective factors and jointly formulate a treatment plan, and then link patients
to supportive services and treatment as appropriate. As much as possible, we
want this to be simple and actionable for every
primary care provider across the state of California. We include a list of
ACE-associated health conditions. And if you all look at this list, I know that the print is really small. But intentionally as
the committee who worked on developing this list, one
of the things that we did was we recognized that things like depression, suicide attempts, anxiety, we put those on the
bottom half of the list ’cause those are the things
that people are really familiar with as being
associated with ACEs. But things like cardiovascular
disease, tachycardia, asthma, diabetes, hepatitis, arthritis, those are some of the things that many providers are less familiar with having a strong
association with ACEs. So these are the adult clinical tools. We also have the same
clinical tools available for pediatrics. And as providers are encouraged to do their treatment planning,
treatment planning consists of number one, applying the
principles of trauma-informed care including establishing trust, safety, and collaborative decision making. But number two,
identification and treatment of ACE associated health conditions by supplementing usual
care with patient education on toxic stress and strategies to regulate the stress response. So for that adult provider, you’ve just identified
a patient with diabetes. In addition to prescribing that metformin, if that patient has a high ACE
score, you also have to say, “You know what, because of your ACEs, “you’re at greater risk of
having a toxic stress response. “And so, in addition to
prescribing this metformin, “I want to talk to you
about the importance “of regulating, recognizing
and responding to “an overactive stress response,” through supportive relationships; mental health treatment, if indicated, it’s not required for everyone; exercise; good sleep
hygiene; healthy nutrition; and mindfulness practices. To supplement with
bringing that piece into the patient’s awareness and helping them be able to address an
overactive stress response is an important part of treating
whatever health condition. We want to ensure to
validate existing strengths and protective factors,
connecting patients to resources and interventions including
educational materials, care coordination, patient navigation, community health workers,
community resources, social work, and mental
health as necessary. And then, follow up using
the presenting symptom. So sometimes, the presenting symptom is going to be behavioral, but a lot of patients with high ACEs may have no behavioral
symptoms in which case you might use the
diabetes or the headaches or the back pain as the clinical indicator and follow along as how are
we doing in our treatment relative to what your
presenting symptom was. So we’ve offered a two-hour training so that every provider in
the state of California, every Medicaid provider, in
order to be able to draw down the reimbursement by July 1 needs to take and attest to having
taken a two-hour training that gives the basics of ACE screening and responding with trauma-informed care. We’re also in the process of developing further training offerings
for the whole spectrum of care providers including
community care workers and other parts of the medical team. But all of these trainings need to meet a minimum curriculum
developed by my office and the Department of
Health Care Services. Now that we’re here at UCSF,
I’m really pleased to say that we also have launched a statewide Learning and Quality
Improvement Collaborative that is being led by Dr.
Eddie Machtinger here at UCSF. Dr. Machtinger, are you in the room? As well as Anda Kuo. Who’s part of the Cal Court? Just raise your hand real quick. So we have a bunch of
clinical leaders here. They’re really leading this groundbreaking nation-leading work on
advancing the standard of care for adverse childhood
experiences and toxic stress. And I believe that 20 years from now, I hope to be back here
having this conversation that just as we’ve seen this reduction in cigarettes daily use, just as we’ve seen this
reduction in maternal mortality, just as we’ve seen this
drop in HIV mortality, so I will be showing you a
slide yet to be developed on the dramatic drop in
adverse childhood experiences and toxic stress in the
state of California. Thank you so much for
your time and attention. (audience applauding) (upbeat music)


7 thoughts on “Applying the Science of Toxic Stress to Transform Outcomes in California

  1. Stop with the Marxist identity politics. This is an embarrassment!
    Teach Legal American students a TRADE to make money and succeed in the world.
    Stop the social studies indoctrination of students.

  2. This is amazing information. I’m so glad this is finding its way into state health policy. Is this information being included in foster parent training and things that foster parents can do to help combat the effects of ACEs?

  3. For those who want to skip the usual bullshit, with which UCTV videos seems to be more and more full – the actual talk starts at 8:26

  4. 16:17 That hard-proves my thesis that bullying is an animal reproductive strategy – that is real-life attack on the future health and living of others, and that bullies should actually be killed (or sterilized, for those who have survived) if we want to improve society and prevent the transmission of anti-social traits.

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