Addressing Toxic Childhood Stress with California’s First Surgeon General, Dr. Nadine Burke Harris

D r. Nadin e Burke Harris

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Marianne O ’ Hare : Welcome to Conversations on Health Care with Mark Masselli
and Margaret Flinter, a show where we speak to the top
thought leaders in health innovation, health policy, care
delivery, and the great minds who are shaping the hea lthca re
of the future.

This week , Mark and Margaret speak with Dr. Nadine Burke
Harris , California ’s first official Surgeon General. She's a noted
expert on the impact of childhood trauma and long term
health outcomes and has launched a program in California
called ACEs Aware seeking to screen all Californians for
exposure to Adverse Childhood Experiences. The goal is to
minimize a lifelong harm to help by prescribing interventions .

Lori Robertson also checks in , Managing Editor of
FactCheck.org looks at m i sstatements spo ken about health
policy in the public domain, separating the fa ke from the facts .
We end with a bright idea that's improving health and
wellbeing in everyday lives.

If you have comments, please e - mail us at chcradio @chc1.com
or find us on Facebook, Twitter, or wherever you listen to
podcast. You can also hear us by asking Alexa to play the
program Conversations on Health Care . Now stay tuned for
our interview with California ’s Surgeon General, Dr. Nadine
Burke Harri s here on Conversations on Health Care .

Mark Masselli: Welcome to Conversations on Health Care I'm Mark Masselli.

Margaret Flinter: And I'm Margaret Flinter.

Mark Masselli: W e're speaking today with California ’s first Surgeon General
Dr. Nadine Burke Harri s. She's a pediatrician, author and renowned thought leader on the Science of Childhood Trauma and Adverse Childhood Events, which she examines in her popular 2014 TED Talk as well as he r acclaimed book, T he
Deepest Well : Healing the Effects of Long - Term C hildhood
Adversity. Dr. Burke Harris received her MD from UC Davis and her m aster's in Public Health from Harvard . Dr. Burke Harris,
welcome to Conversations on Health Care .

Dr. Nadine Burke Harris: Thank you so much for having me .

Mark Masselli: Congratul ations on California ’s first ever S urgeon G eneral and
that selection I think speaks so powerfully to the intent. I'm wondering i f you could talk a little bit about Governor
Newsom ’s decision to create the role of S tate S urgeon G eneral
and choosing you as t he first physician to hold that post and

D r. Nadin e Burke Harris

tell our listeners if you will.

Dr. Nadine Burke Harris: I n his executive order creating the role of California S urgeon
G eneral , Governor Newsom actually wrote in the executive
order, a recognition that early social determinants of health
are some of the root causes of some of the most serious and
expensive healthcare challenges . H e recognized that these
challenges are not only serious, but inequitable. He created
the role of State Surgeon General specifically to mar shal the
insights and the energy of our medical professionals,
academics, public servants, to be able to address these critical
public health challenges to recognize that while we are as a
state, we have the department of social services addressing
child m altreatment, we have all of these pieces that are
addressing each component of these issues. One of the pieces
that are critical is to have this high level empowered
leadership to work in a cross sector way , to bring some real
innovative approaches to addr essing some of our most
diff icult public health challenges.

Margaret Flinter: Well, Dr. Burke Harris, we now know that exposure to trauma
in childhood has very dramatic , very far reaching effects on
health outcomes . For our listeners, can you help them
und erstand what you mean by trauma, toxic stress, Adverse
Childhood Events or ACE s as we've come to know them, and
the toll that it is exacting on populati on health right as we sit
here?

Dr. Nadine Burke Harris: Yeah, so I think that it feels fairly intuitive that early adversity
may be associated with later life, health and mental health
challenges. But what's really fascinating was that we learned
from a very large scale study that was conducted by the CDC
and Kaiser Permanente about the strong association b etween
stressful or traumatic events in childhood and some of the
leading causes of death in the United States like heart disease,
cancer, chronic lung disease, and even Alzheimer's . This
groundbreaking study that was conducted by the CDC and
Kaiser Perman ente called the Adverse Childhood Experiences
study, where they looked at 10 categories of Adverse
Childhood Experiences and these include physical, emotional
and sexual abuse, physical or emotional neglect, or growing up
in a household where parent was me ntally ill , substance
dependent incarcerated where there was parental separation
o r divorce or domestic violence. Those are the 10 traditional
Adverse Childhood Experiences .

T he science that's emerged in the last two decades shows us
that the mechanism by which this happens, right, the least

D r. Nadin e Burke Harris

common denominator is that when an individual has these
experiences, and especially during childhood when our brains
and bodies are just developing , the repeated activation of our
body's biological stress response, rele asing stress hormones
like adrenaline and cortiso ne actually changes the
development of children's brains and bodies . T his is what leads
to the increased health risk and it's known as the t oxic s tress
r esponse . This over - activity of our biological stress r esponse
leading to increased risk of health problems is what's now
known as the t oxic s tress r esponse . Toxic stress is really the
kind of root cause of many of the most serious and expensive
health challenges that we're facing in our nation.

Mark Masselli: Dr. Burke Harris, I think some of us learn through studies and
you mentioned the 1990s seminal study that came up, but
others are really, it's about storytelling that really impact
them . T his whole issue was brought home to you by a young
patient named Di ego. I wonder if you could just share that
story with our listeners.

Dr. Nadine Burke Harris: As a clinician, as a pediatrician, I didn't learn about any of the
science when I was in medical school or residency . Even
though this research was conducted in 1 997 , as a pediatrician
working in a vulnerable community in San Francisco, what I
was seeing clinically was that my patients who , as I was getting
their history and hearing history of adversities that my patient
had experienced , I happen to notice that my patients with the
most significant histories of adversity also happen to have the
worst health outcomes whether it was asthma or behavioral
problems or even auto - immune disease . T he kind of striking
issue that stopped me in my tracks was one day I was in c linic
and I had a new patient who m I call ed Diego.

This was a seven year old boy who came to see me for regular
physical . I noted that he had lots of challenges with behavior
and attention, he also have asthma . But when I measured his
height and weight, hi s height was the average for four year old
boy, which was striking because he was seven years old. What
I learned was that he had experienced a sexual assault at age
four, and essentially stopped growing. I was just absolutely
shocked and as I was working with my colleagues, the
endocrinologist who specializes in hormones, all of these . I
said, have you ever heard of this before that a trauma might
be the reason that this boy is not growing? Right , I've heard of
malnutrition . T hat's w hat caused me to immers e myself in the
science about how trauma and early adversity affects the
develo ping brains and bodies of kids.

D r. Nadin e Burke Harris

Margaret Flinter: Well, Dr. Burke Harris, I'd like to talk with you a little bit about
the mechanisms of how trauma and toxic stress in childhood
literally changes your biologic makeup and even your DNA
structure. I have done a deep dive into these biologic
mechanics of how traumatic events in childhood can affect the
trajectory of your long term health . Y ou really don't sugarcoat
your findings in your book, 9 out of 10 of the leading causes of
death in the United States are directly linked to some kind of
childhood trauma or adversity. Our listeners, I think are really
interested in really hearing some of t he science behind this
reality.

Dr. Nadine Burke Harris: Yeah, so our increased understanding of how A dverse
C hildhood E xperiences can lead to this over - activity of t oxic
s tress r esponse . It builds off of our understanding of the last
several decades of brain biology and how there's much more
that we know and understand now about how critical the early
years are in brain development, and in actually shaping what
we call the d evelopmental t rajectory , the subsequent
development of the brain in response to experiences in early
childhood. But one of th e things that's really fascinating is
advances in scientific research like functional MRIs and
genomics and metabolomics has allowed us now to be able to
measure things that we could never measure before.

W hat we now understand is that Adverse Childhood
Ex periences is also associated with changes in the way our
hormones are released and how they act on the brain and
body. It also affects the development of our immune system .
W e know that many of the leading causes of death are
associated with diseases of ch ronic inflammation , and high
doses of adversity actually can lead to changes in the way our
DNA is read and transcribed , something that's called
Epigenetic Regulation . When you change the DNA, it changes
the way cells in the brain, the immune system, the h ormonal
system s react for the entire lifetime . Th ese are all now part of
what we understand to be the t oxic s tress r esponse .

These advances in research are now targeting what are the
factors and intervention that can heal an overactive stress
response ? S le ep, exercise, nutrition, mindfulness, mental
health and healthy relationships , b ut we're actually
recognizing now that these factors , and we can measure them
yeah, reduce stress hormones, reduce inflammation , enhance
neuroplasticity, which is the ability o f brain cells to form new
connections, and they delay cellular aging. T his is an exciting
new field of science in medicine.

D r. Nadin e Burke Harris

Mark Masselli: W e're speaking today with California ’s first Surgeon General
Dr. Nadine Burke Harris. She's a pediatrician, author an d
renowned thought leader on the science of childhood trauma
and Adverse Childhood Events . Dr. Burke Harris, prior to
becoming California's first Surgeon General, you were a
practicing pediatrician in an underserved community in San
Francisco and founded t he Center for Youth Wellness, an
organization that seeking to harness the power of science,
clinical best practices to address worse effects of ACEs. You’re
now on a mission to make screening for Adverse Childhood
Events as common as any other pediatric me tric. Tell us more
about the system you're deploying in California , the ACEs
Aware Initiative .

Dr. Nadine Burke Harris: This is something that I am so excited about . T he ACEs Aware
Initiative is really a first of its kind, statewide initiative.
Governor Ne wsom when he appointed me also allocated in his
budget $40.8 million to reimburse providers for screening for
ACEs and respo nding with trauma informed care.

Mark Masselli: Well, that’s great.

Dr. Nadine Burke Harris : Also allocated $50 million to be deploy ed over three years on
training providers, how to screen , how to respond with t rauma
i nformed c are and supporting an infrastructure that's
necessary to be able to effectively screen for ACEs in p rimary
c are. The National Academies of S ciences, E ngineering , and
M edicine just came out with a consensus report on this that
was released in July. O ne of the key things that we know early
detection and early intervention improves outcomes , and so
how do we systematically deploy early detection and early
interventio n? It has to be through p rimary c are. R ight now, if a
young person or an adult has a mental health diagnosis if
they're depressed or suicidal, we say oh, wow, let's look at
your history of trauma. But that means that that biology of
toxic stress all that t hose stress hormones have been doing
their work in that person's body for years and possibly
decades b efore we identify, right . W e're essentially identifying
stage four.

I f we look at anything else, if we look at cancer, if we look at
any other public heal th threat, one of the most important
advances has been improving outcomes, has been doing early
detection so that our interventions can be less expensive.
They're more likely to be effective, and they put less strain on
our healthcare system. H ere in Calif ornia we just , I ’ m so proud ,
launched our ACEs A ware I nitiative, the training website
where any primary care clinician can go online . Y ou don't even

D r. Nadin e Burke Harris

have to be from California , can sign up for the training and get
the best of our clinical protocols, a clin ical algorithm on how to
screen for ACEs , how to recognize the signs, and how to
res pond with trauma informed care.

Margaret Flinter: Well, Dr. Burke Harris, all of this requires that we think about
our models of care and practice. But when we think about this
issue of training, specifically, share your thoughts with us on
how we begin to shift our health care curricular to prepare our
future clinicians to work in interprofessional teams that can
better address the causes and t he results of childhood trauma .

Dr. Nadine Burke Harris : A s part of the ACEs A ware I nitiative, not only has our team
taken the best practice of the science, that until very recently,
wasn't in clinical practice. J ust as I talked about how advances
in science have really helped us now u nderstand better than
we ever have before , h ow our environments and our
experiences shape our biology . W e also have to recognize that
how do we coordinate our clinical response , b ecause it can't
just end in the exam room.

An important part of the work that is happening now is this
notion of who does what , right ? How do we divide and
conquer so that it's not overwhelming for any individual
practitioner ? W e know that trauma informed care, team
based care, all of these things are best practices for addressing
toxic stress. When we recognize that our environment shapes
our biology, then that question of what happens in the
primary care clinic , and how do we coordinate with
community resources as well, to make sure we bring them to
bear on behalf of our patients f ollow ing up for accountability
and looking at outcomes.

As part of the ACEs A ware I nitiative that we're doing in
California, we are actually creating a learning and quality
improvement collaborati ve that will be deployed in 50 clinics
across our state to advance best practices, collect data and
share the best practices with any provider around the country
who wants to use them.

Mark Masselli: Well, that's great. You know, Dr. Burke Harris, I was just
thinking about an interview we just had with Dr. Steven Woolf
from Virginia Commonwealth University who was just released
a seminal report on the fact that 25 to 64 year old were dying
earlier . I couldn't help but, as you were talking thinking about,
we've really got to start at the youngest age, trying to chan ge
the trajectory if we're going to turn that around. I can't help
but think the work that you're doing will have a pr ofound
impact over the long term , and I don't know if you have any

D r. Nadin e Burke Harris

thoughts on that.

Dr. Nadine Burke Harris : One of the challenges that w e see is that when you have an
exposure that happens in childhood, but the outcomes that
you see are typically measured in adult morbidity and
mortality, right ? T hat question of how do we make the value
proposition for the investments in our systems and
in frastructure that's necessary to facilitate early detection ,
h ow do we know that it's transforming outcome? H ow do we
show that it's transforming outcome? T his is part of the reason
why using the framework and screening for Adverse Childhood
Experiences is so critically important , b ecause while Adverse
Childhood Experiences are not the only experiences that
increase the risk for toxic stress . T he ACEs don't ask about
discrimination. They don't ask about separation from your
parent because they were deported right? Like they don't ask
about any of those things.

However, what they do allow us to do is because we have
these very large dataset where we know for an individual who
has four or more ACEs , their risk of kidney disease is 1.7 times
as likely to have k idney disease. T hat means is that if we
screen everyone, we do our interventions, and then we track
the health outcomes of our population, we can not only
measure our improvement, but we also have ability to
quantify the cost , b ecause we know the annual co st of treating
kidney disease . W e know the annual cost of treating
cardiovascular disease. T hat's why the ACEs framework is not
just an important tool for raising awareness, prevention and
early intervention. It's also a very important tool to establish
th e metrics by which w e will justify our investments.

Margaret Flinter: We have been speaking today with pediatrician, author and
expert on the science of childho od trauma, California’s first
Surgeon General Dr. Nadine Burke Harris. For information on
the to ols and screenings for ACEs in your health c are practice
y ou can visit www.aces aware.org by following her on Twitter
@ Dr. Burke Harris . Y ou can find her very popular TED T alk
@ted.org and read her book The Deepest Well : Healing t he
Effects o f Long - Term Chi ldhood Adversity. Dr. Burke Harris,
thank you so much for your tenacity, your intellectual rigor,
curiosity, your dedication to improving the health of America's
children and all people and for joining us today on
Conversations on Health Care.

Dr. Nadine Bu rke Harris : Thank you so much , i t's been my joy.

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D r. Nadin e Burke Harris

Mark Masselli: At Conversations on Health Care we want our audience to be
truly in the know when it comes to the facts about health care
reform and policy. Lori Robertson is an award - winning
journali st and Managing Editor of FactCheck.org, a
nonpartisan, nonprofit consumer advocate for voters that aim
to reduce the level of deception in US p olitics. Lori, what have
you got for us this week?

Lori Robertson: Democratic presidential candidate and former Vice President
Joe Biden cla ims without evidence that “ more people are
coming home from Iraq with brain cancer” than any other war.
He also suggested that burn pits open air waste incineration
sites are behind the purported increase. Existing statistics do
not indicate that Iraq veterans are more affected by brain
cancer than other veteran groups. Although no comprehensive
data is available to definitively s ay one way or the other.

A 2011 report by the National Academy of Sciences on the
long term health ef fects of burn pit exposure in Iraq and
Afghanis tan found that there was “ inadequate / insufficient
evidence to determine whether there is an association with
cancer. ” Biden's comments came during a CNN Town Hall in
Iowa on Veterans Day when he was asked by a woman in a
military family how he as president would address the lack of
mental health care and resulting homelessness amongst
service members. After promising to provide more services to
veterans, Biden brought up his eldest son B eau , who served in
Iraq and died from an aggressive brain cancer in 2015.

We were unable to find any support for Biden's claim that
more people are coming home from Iraq with brain cancer
than ever before. His campaign did not reply to our request
asking for a source for his stat ement. According to a 2015
Veterans Affairs Post Deployment Surveillance report, brain
cancer prevalence was 0.04% for Vietnam veterans and 0.03%
for both Gulf War veterans and those who served in Iraq and
Afghanistan post 9 / 11. For more on this topic see our website.
I'm Lori Robertson, M anaging Editor of F act C heck.org.

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Margaret Flinter: FactCheck.org is committed to factual accuracy from the
country's major political players and is a project of the
Annenberg Public Policy Center at the University of
Pennsylvania. If you have a fact that you'd like checked, e - mail
us at www.chcradio.com , we'll have FactCheck.org's Lori
Robertson check it out for you here on Conversations on
Health Care.

D r. Nadin e Burke Harris

[Music]

Mark Masselli: Each week Conversations highlights a bright idea about how to
make wellness a part of our communities and everyday lives.
Students of public health are often tasked with devising
interventions for addressing some of health biggest
challenges. F or Harvard T . H . Chan School of Public Health
student s, Dan Wexler and Priya Patel t heir idea netted an
award. The students were tasked with addressing food
insecurity in underserved parts of the world, including i n
neighborhoods in their own backyard. They thought of the
current trend of healthy meal or meals services like Blue Apron
and wondered w hat if we modified that business model to
serve the needs of those living in food desert . I nstead of home
delivery approach they designed refrigerated kiosk that could
easil y be placed in local neighborhoods.

Dan Wexler: There is no delivery system door to door per se , a nd that by
going and setting up these kiosks in the community, you can
have a very lean design , you can have -- you don't need a
storefront. Y ou are very much addressing the need of access
by physically saying, hey, here is healthy food, really thinking
about how can we take all those lean design principles to
facilitate access that really, I think making a solution th at has a
potential for impact.

Mark Massell i: T hey also conducted research with local ethnic groups to
create recipes that woul d resonate with their families.

Dan Wexler: Then we just went down to the community and did taste
testing at the F armers ’ M arket and talk to people and said, you
know, do y ou like this? What do you want to be able to eat for
dinner ? B asically, we have some dishes that is si milar textures,
similar spices.

Mark Masselli: Customers can simply walk to the kiosk and purchase their
meal kits with the snap cards or cash . They added benefits , the
kiosk will be run by the residents of the neighborhood, giving
them an opportunity to purchase the kios k and run them like a
franchise. Their idea earned them the Rabobank - MIT Food and
Agrib usiness Innovation prize . A low cost portable healt hy
meal service placed in portable kiosk and food desert
neighborhoods to address the problem of poor nutrition , n ow
that's a bright idea.

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Mark Masselli: You've been listening to Conversations on Health Care. I'm
Mark Masselli.

D r. Nadin e Burke Harris
Margaret Flinter: An d I'm Margaret Flinter.
Mark Masselli: Peace and Health.
Marianne O ’ Hare : Conversations on Health Care is recorded at WESU at
Wesleyan University, streaming live at www.chcradio.com ,
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