Berkeley Talks transcript: Nadine Burke Harris on the health impacts of childhood stress

Michael Lu: For those of you whom I haven’t met, my name is Michael Lu. I’m the dean at the School of Public Health at Berkeley and I want to welcome all of you to opening night of the Dean’s Speaker Series. Now before we start, I just want to take a moment to thank our campus co-sponsors, the Goldman School of Public Policy and the Haas Institute for a Fair and Inclusive Society. Thank you for your support, and I’m really looking forward to our partnerships in the coming years in advancing health equity and social justice here at home and around the globe.

This evening I’m continuing a tradition of bringing distinguished public health leaders to come and talk with our Berkeley public health community. We’re honored tonight to have with us Dr. Nadine Burke Harris, the first surgeon general of California. Nadine was appointed surgeon general by Governor Newsom in January this year. She’s an award-winning pediatrician, researcher, and advocate with a distinguished career that focused on serving vulnerable families and combating the root causes of health disparities. She’s a Cal alum with a bachelor’s degree in integrative biology from Berkeley. She received her MBA from UC Davis, her MPH from T.H. Chan School of Public Health at Harvard, or better know as Berkeley of the East, and completed her pediatric residency at Stanford. In 2013, she founded the Center of Youth Wellness at Bayview Hunters Point in San Francisco, designed to transform the way society responds to children exposed to childhood trauma and toxic stress. Her TED Talk, How Childhood Trauma Affects Health Across a Lifetime, had been viewed over six million times.

Her book, The Deepest Well: Healing the Long-Term Effects of Childhood Adversity, was called indispensable by the New York Times. She’s the recipient of many distinguished awards, including the Humanism Award from the American Academy of Pediatrics, one of the highest honors bestowed by the APA. For the past year and a half, I have had the honor of serving alongside Nadine on the committee for the National Academies of Sciences, Engineering and Medicine, which just released a report in July called “Vibrant and Healthy Kids: Aligning Science, “Practice, and Policy to Advance Health Equity.” The report built on a previous institute of medicine report called “Neurons to Neighborhoods,” and draws upon all the scientific advances over the past two decades to develop a roadmap on what our nation must do to make sure that all of our children no matter where they’re from, or the families that they’re born into, or the color of their skin, have a fair shot at reaching their fullest potential.

Nadine and I worked on chapters summarizing the neurobiological sciences and envisioning health systems transformation, and over the past year and a half, I’ve come to admire the power of her extraordinary intellect, and, more importantly, the authenticity of her deep-rooted passion for health equity and social justice. So as a Californian, I just have this to say, Governor Newsom, good job. And, Nadine, we’re so lucky and so proud to have you championing public health and health equity for the people of California. So, thank you. All right, can you hear me? So let me get this conversation started, and this is how this is gonna work. This is not just a conversation between Nadine and me. It’s really a conversation between Nadine and all of our public health community. So I’ll get the conversation started, but when you came in, you should have gotten a note card, right?

Okay, so let’s go ahead and get started, and I hate to start a conversation with a stupid question, but the great thing about being a new dean is you’re kinda still in that honeymoon period– So you get to ask all sorts of stupid questions and people don’t really judge you, for now. So, Nadine, you’re the first surgeon general of California. There are only three states in the nation that actually has a surgeon general. So what exactly does a surgeon general do?

Nadine Burke Harris: I will say, first of all, I love stupid questions ’cause I was also always the one asking them in medical school and public health school. But, yeah, so what the heck does a state surgeon general do? So here in California, we have been, I think, extraordinarily fortunate that we have a governor that recognizes that early social determinants of health are a root cause of some of our most serious, pervasive, and expensive health consequences that is facing the state of California. And as a result, what Governor Newsom did in literally his first day in office was he wrote an executive order to create the role of surgeon general, and the explicit directive of the surgeon general was, number one, to marshal the insights of our scientific community, our public health community, our public servants, and everyday Californians to be able to tackle these serious and inequitable challenges that are facing California today.

The second big part of the role of state surgeon general is really to be a medical advisor to the governor, right? To bring together the best science and to share that in being an advisor to the governor around health-related issues. And the last part which I wanna say it’s my favorite part, but I think, I love science just as much as I love advocacy, but it’s really just to be public health champion, right? It’s to get out there and share with the public, be a voice for not only raising awareness around these serious and inequitable challenges, but also to be a source of solutions and lifting up what we know and what works.

Michael Lu: So on this last role, being a voice for the public’s health in California, and as I think of the surgeon generals who have effectively, who have effective in exercising that bully pulpit, right? You think of C. Everett Koop with smoking. You think of David Satcher with health disparities. Now Californians face a lot of great public health problems. Some of the greatest existential threats in the 21st century. There are all sorts of problems that you can take on, from climate change, immunization, immigration. You took on something that not that many people have heard of outside of our struggle — something called ACEs.

What are ACEs and why is it that important?

Nadine Burke Harris: The term ACEs is an acronym for Adverse Childhood Experiences, which comes after this study by the same name that was done by the CDC and Kaiser Permanente in which they asked 17,500 adults about their histories of 10 categories of adverse childhood experiences, and those include physical, emotional, and sexual abuse, physical and emotional neglect, or growing up in a household where a parent was mentally ill, substance dependent, incarcerated, where there was parental separation or divorce, or domestic violence. And what they found were two things that were really groundbreaking.

Number one is that ACEs are incredibly common, so this doesn’t just happen in certain zip codes, just certain people over there. Two-thirds of their population at Kaiser San Diego which was 70% Caucasian, 70% college educated, had experienced at least one ACE, and one in eight folks had experienced four or more. What we see in the two decades since that study has been published that that prevalence is very similar nationally, and, in fact, globally, right? So very high prevalence, and the second piece, which I think was kind of really groundbreaking, was unlike the common wisdom that I think many of us have that if you have a rough childhood, yes, you’re more likely to have issues with a mental health or substance dependence, right? And they did find an incredibly strong dose-response relationship between early adversity and mental and behavioral outcomes, but also with some of the leading causes of death in the U.S., including heart disease, cancer, stroke, diabetes, Alzheimer’s, et cetera.

And so there was this dose-response relationship where a person with four or more ACEs, we’re talking about double the risk for heart disease, 2.5 times the risk for stroke, triple the risk of chronic lung disease. And so very similar, in a similar fashion of the way past surgeons general have looked at some of the most pressing health challenges and the leading causes of death, and asked that question, what is a modifiable root cause, right? Similarly, so when you look at smoking, you can take on, you can advance the care for lung cancer, and for emphysema, and for heart disease, and all these downstream outcomes, or when we launched a coordinated effort to reduce the prevalence of smoking, what we saw was improvements in all those outcomes.

Similarly, I can take on all of these different factors, but we recognize that childhood adversity is a common root cause, and not only that, it also gives us really powerful insights into the mechanisms of some of the most urgent issues of our day, specifically around when we understand that accumulated adversity, cumulative adversity, actually has an impact on our stress response system, right? And that impacts our later risk of heart disease, right? It helps us understand that when a black boy is walking down the street and gets profiled, and gets stopped, that same stress response is what’s being activated, and the more time it’s activated, the greater the risk to your health, right? And, similarly, we’re seeing that around the country as immigrant communities are facing ICE raids. This impact of cumulative adversity has a direct impact on long-term health and understanding those mechanisms as a root cause mechanism, I think it’s foundational.

Michael Lu: So childhood trauma and heart disease, childhood trauma and mental and behavioral health problems. Now I’m in a room full of folks who are really well-trained in epidemiology and they are not gonna let me get away without asking this question about that association doesn’t always imply causation.

Nadine Burke Harris: Mm, yes.

Michael Lu: What’s the biological, plausible mechanism kinda linking to childhood trauma to all of these later outcomes?

Nadine Burke Harris: Oh, so this is like my favorite thing in the world. So there are two pieces. I’m gonna answer the question in two ways. So one is the biological mechanism, which is understanding that we all have what we call our flight-or-fight response. When we experience something scary or threatening, it activates the amygdala which is the alarm, and that activates our biological stress response, including stress hormones that release adrenaline and cortisol. And so our heart start to pound, our pupils dilate, our airwaves open up, right? This is what the stress response was designed to do and it saves our life from a mortal threat. But what the science shows us is that if that stress response is activated repeatedly, too often, without adequate buffering, caregiving systems, it can become deregulated and it can become overactive. And one of the critical pieces is that timing matters.

So, here at Berkeley, I had the privilege of studying under Dr. Tyrone Hayes, who is here in the room, in the Hayes lab studying amphibian endocrinology, right? And what we found, what learned in the Hayes lab is that when we expose tadpoles to corticosteroids, stress hormones, that the impact that those stress hormones had on those tadpoles was really dependent on how close those tadpoles were to metamorphosis. So if they were more mature, right about to hit metamorphosis, those stress hormones were adaptive and it helped them speed up metamorphosis and jump out of that drying pond, whatever is causing them the stress, but if they were too little, if it was too early in their development, it led to a series of changes that ultimately, dramatically diminished their survival. So the timing, that same exposure of stress hormones, the timing makes a difference, and that’s the same thing that we see in humans as well. Because children’s brains and bodies are just developing, high doses of adversity in childhood and especially in the first hundred days to the first five years have an outsized impact on children’s developmental trajectory, and it’s not just the structure and function of children’s developing brains, but it’s also their developing immune systems, their hormonal systems, and even the way their DNA is read and transcribed, their epigenetic regulation.

So that is some of the, the kind of the juicy science behind this, but when we talk about ACEs and heart disease, for example, I think it’s really, really important for us to recognize when we look at the criteria, if we’re looking at causal inference, right? There’s the dose-response relationship, you have to understand that, which we see with ACEs. We have a plausible biological mechanism which we also see. There’s also when we see in natural experiment, right? We also see these in other species, so we’re making these cross species. So the rigor of the data, I hear people say sometimes, “Well, the ACE data,” and, “Was that the right study?” and, “Was it structured the right way?” and, “Was it controlled right?” And it’s like, this is just one piece of information that we are using, assembling, with a much broader body of science that goes everywhere from our broad-scale epidemiological surveillance data, which we have from over 20 countries around the world, to the most basic molecular mechanisms about how our DNA is methylated when we’re exposed to high doses of adversity. So it’s the full spectrum.

Michael Lu: So that was obviously a setup. When we were at the National Academies, she just could not stop talking about biology. So let me start to ask you some harder questions. So, what can the state of California do about childhood trauma and toxic stress?

Nadine Burke Harris: So, there is not only a lot that we can do, but I’m really excited to talk about what we are doing. One of the biggest projects that I’m taking on coming into the role of state surgeon general is leading California’s efforts to implement routine screening for Adverse Childhood Experiences among our Medicaid population. If there’s one thing that the evidence shows us, is that early detection and early intervention improves outcomes. And so as we move towards a statewide effort for routine screening to enable early detection and early intervention, that is my amazing job, and what we’re doing there is currently we’re in process of, I wanna say developing, we’re actually adapting an existing training, but developing a training for our 88,000 primary care providers to, number one, understand best practices for screening for Adverse Childhood Experiences, and, number two, understand the fundamentals of trauma-informed care, right? And, for once, this is not an unfunded mandate.

Governor Newsom in this year’s budget put $40.8 million to reimburse providers for screening for ACEs. If you’re a Medicaid provider in the state of California, starting in January of 2020, when you do an ACE screening, you will get a reimbursement for every single patient, man, woman, and child that you screen. And also included in the budget was $50 million, and we’re hoping to draw down some additional dollars in a federal match, to train providers on how to do the screening and how to respond with trauma-informed care. That level of investment at a statewide level is unprecedented. However, as you and I worked together on the National Academies’ committee, one of the things that I feel maybe most excited and happy about as one of the products in the “Vibrant and Happy Kids” report is this framework of understanding that fundamentally at the core we have our exposures, and experiences, and how they impact our biology, right?

So, how the activation of the stress response leads to changes in brain development, and immune system, and all of those things, but then that next level is this framework of understanding how the family system impacts the likelihood that someone will be exposed to adverse experiences. And then enveloping that family system is our community, the ecological systems, our neighborhoods, our health care systems, our structural systems, and then on top of that are really some of the structural frameworks in terms of our policies and our social infrastructure, right? And all of those things impact the odds of exposure and the odds of developing morbidity and mortality, right? Disease and death once you’ve been exposed.

One of the things that I’m really proud of, this is like my favorite thing about this job. Can you tell this is my dream job? Is that I get to not only work at that level of working with clinicians to advance their clinical practices and implementing routine screening, but I also get to sit across a table from the superintendent of public education and have a conversation about how our educational systems should be delivering doses of buffering, right? And how we need trauma-informed practices and policies in our educational systems. I literally was stopped on the street by the gentleman who is the head of our state, I think it’s police officers, it was an organization, and he was like, “Oh, my gosh! “Police officers are like, ‘We wanna be in this! “‘We wanna be doing trauma-informed policing!'” I was just like, “Oh, my God, give me your card,” right? I get to work with my colleagues in the governor’s office and across state leadership on how we’re supporting low-income families, on how we’re moving towards enhancing paid family leave, so that parents and kids can establish that bonding connection that has life-long impacts. This is all of the work that we are doing right now in the current administration.

Michael Lu: Wow, so did you always know that you wanted to become surgeon general when you were growing up? Tell us about, okay, your life story and how did you get to this position?

Nadine Burke Harris: I think that’s just what every girl dreams of. Isn’t it? Am I wrong? So, true story, I knew that I wanted to be a pediatrician from the time I was 4 years old, and when I was 5, I wrote a letter to my doctor and I was trying to figure out how God got the skin on because there were no buttons and there were no, like there are no zippers. Ultimately, I figured it out. He did not write back, but I figured it out, which was the drawstring theory. That’s what your bellybutton is for. But I always, always, always wanted to be a physician, and it could be related to the fact that my dad is a biochemist and my mom is a nurse, so I kind of grew up in this scientific household, but none of my brothers are in the sciences, so who knows.

The funny thing about it is I always wanted to be a physician, I always wanted to serve underserved communities and do community health. I think that was just part of my background. I’m a proud immigrant. My family came to the United States from Jamaica, and I always grew up with a really powerful sense of community. Oh, some Yardies in the house! But, yeah, I always grew up with this really, really strong sense of community, and so that was always really powerful. And so even when I was in medical school and I learned about this concept of like, oh, I can go to public health school, right? Like, that was a beautiful, exciting moment for me. I will tell you that when the Newsom administration called me and they said that we would like for you to consider being the surgeon general of California, I was like, “Oh, there’s no such thing ” as a surgeon general of California.”

When I actually sat down with the governor, he’s like, “I know, I’m making it,” and I was just like, “Oh!” But this is, obviously, my dream job. I feel like this is something that I was born to do in terms of all of my experiences. My experiences of growing up black in America. My experiences of being an immigrant. My experiences of dedicating my career to serving underserved communities, but then also my profound love of science. Like, I’m just such a science geek, like that’s my, and I think the other thing that I love is that I just love people. I love connecting with people, I love hearing people’s stories, and I believe and I feel like this is something that I’ve believed for a long time but I learned even more deeply and profoundly in public health school, that we are powerful. We are powerful. Our voices are powerful. The way that we take that science and filter it through this prism of our lived experience to generate scientific insights that can change outcomes for so many people. That is powerful. And so, yeah, for me, when I got the call, and I don’t know if I should admit this publicly, but when I got off the phone, like when I hung up the phone, the first word out of my mouth was an expletive — because I knew that my life was about to change in a really, really powerful and exciting way.

Michael Lu: Well, I’m actually really glad that you brought up black immigrant woman because all day I’ve been thinking about, well, “How do I bring this topic up?” These are some of the hardest conversations that our society is enabled to have today, but I always believed that university, especially schools of public health, ought to be better. So when you were appointed, the headline for one of the news story was “A Black Immigrant Woman Is Now the Most Powerful Health Official in California.” How do you think your background has helped you get here, and how do you think your background has hindered your way, your path here?

Nadine Burke Harris: Many of the things that immediately come to mind when you ask that question are the same answer for both questions. When I started at UC Davis School of Medicine in 1997, it was immediately after the Baki decision. It was after Prop 209 here in California, and for those of you, Prop 209 essentially eliminated the use of affirmative action in policies and decisions. So, it was an interesting experience going to UC Davis at that time, and I had one, a friend of mine who had, we had done our undergrad together here at Cal — Go, Bears. We had this very interesting experience. On four different occasions in my first year of medical school someone told me, “I know you’re only here because of affirmative action.” I’m like, “There isn’t even any affirmative action anymore. How can you say that?” But something to the effect that you don’t belong here.

And, I mean, one of the interesting things is that age-old saying, right? It’s that age-old saying that you have to be “twice as good to get half as far.” For me, it really strengthened my resolve to be excellent, and I think that my resolve to be excellent was strengthened by a number of different experiences. I think, on the one hand, by those who doubted me and sometimes expressed it to my face, and on the other hand, my resolve for excellence was strengthened by my commitment to serving underserved communities because I had the experience of seeing, for example, when I was in medical school and I was the co-director of a student-run clinic for uninsured communities in Sacramento that there were so many fewer providers to care for people who don’t have a lot of money, low-income people of color primarily, and I felt like, “Oh, these people need the best doctor because that’s their only resource, and if you don’t know what you’re doing, they won’t know.” And so it is such an imperative for me to hit the books, to know my, just to know my science, my medicine, my clinical practice inside and out.

And then I feel like one of the most amazing things as a scientist is that breakthroughs in science come when you combine the scientific knowledge with a different way of looking or seeing things, and I felt that my experience, both my personal experience as a black woman and an immigrant, but also the proximity that I was able to experience with my patients gave me so many insights, stuff that I didn’t learn in medical school. So that I never would have, like, oh, how is it that we would, like something that I wrote about in my book. One of my patients said to me, I was caring for a patient who had asthma and we were trying to figure out her asthma triggers. So I’m like, “Could it be pet dander?” All this stuff that I’d had learned in my medical training. My excellent training at Stanford, right? Could it be pet dander? Could it be cockroaches? Could it be pollen? Could it be cleaning products? What is it could be triggering this little girl’s asthma? And her mom said to me, “Oh, I noticed that my daughter’s asthma tends to act up every time her dad punches a hole in the wall.”

That’s where my brain takes the combination of all the science that I learned in medical school, and all the public health, but it filtered it through this prism of experience that I never would have had if I wasn’t in those circumstances and having that conversation with that mom.

Michael Lu: Thank you. We’re gonna start collecting your questions, but while we’re doing that, we got a lot of students in this room and many of them aspire to be you someday. What knowledge, skills, tools, experiences that knowing what you know today you wish you had, that you had spent more time learning when you were getting your MPH at Berkeley of the East?

Nadine Burke Harris: Well, the first thing I will say to all the public health students out there is go ahead and pay attention in biostats and epi, y’all, because you will use that. Those are the tools that I still use on a regular basis today, but, frankly, I think that the greatest tool that I learned as part of my public health training was really a frame of reference. How to see and interpret what was going on around me and I think that most of the folks in this room will recall or recognize day one of public health school. What you see is that population curve, right? And you slice and dice that population curve for whatever disease or condition in lots of different ways, and you can look at the tail-end of the curve for the folks who are most severely affected and look at what do strategies that target that part of the curve, what are they able to accomplish? Or what happens when you shift the curve, right? And I think that in medical school, my training really was, okay, someone’s in front of me, they have a condition. How do I treat this person in front of me? And it was really my public health training when I was seeing child after child, after child who was experiencing high doses of adversity, and whether it was asthma, or attention deficit, or some autoimmune disorder to move out of that framework that I was trained in in medical school of what’s the treatment for this patient to the framework that I was trained in in public health school of what’s the treatment for this community, right? And that was really, really powerful. So I will say that more, my experience is being grateful every day for my public health training because it really was a wonderful experience.

Michael Lu: All right, let me call up our student who’s going to be reading the questions, Omonevia Abogadi.

Omonevia Abogadi: Good evening. I’ll be reading the questions.

Michael Lu: Thank you, I’m gonna have a tough time at graduation. I just know it. But you’re a one-year MPH student in our interdisciplinary program and you’re between your second and third year of medical school where?

Omonevia Abogadi: Yes, I attend medical school at Wright State University Boonshoft School of Medicine in Dayton, Ohio, and I also went here for undergrad. Go, Bears! All right, and do we have, we’ve got questions. Okay, so the first question for you Dr. Burke Harris is: What has been the most challenging and rewarding thing in developing your role as the first surgeon general in California? What has surprised you?

Nadine Burke Harris: I’ll answer the second question first. So what has surprised me the most is the talent, brilliance and dedication of my colleagues in state service. I am going to say, whatever that term is, “Good enough for government work,” where did that come from? I, honestly, I think that there’s, I will have to say that I came into this role and I have potentially with some, I just had no idea to expect such amazing talent and dedication from my government service colleagues. I mean, really unparalleled. That has been my biggest surprise, and it’s been a really wonderful surprise.

What has been the biggest challenge? Government bureaucracy is a very interesting experience. This is my first time in government and I was sworn in in February, and understanding how the process works, right? That whole machinery of government, the budgeting process, the legislative process, and the fact that it, for real, if it’s really not in the budget, it really can’t happen. I’m like, “Really, can I get a stapler?” That I think has been the biggest challenge on the one hand, but amazing learning about how things actually work. I think for most of us in this room as we’re thinking about public health, we’re thinking about developing, implementing, or influencing policies that impact very large numbers of people, and there’s no more powerful tool to do that than in government. So understanding how government works and really the nuts and bolts of it has been a great education and sometimes makes me wanna pull my hair out.

Omonevia Abogadi: Okay, next question. As a pediatrician in a low-resource FQHC setting, I am concerned about the possibility of universal ACEs screening. I piloted the PEARLS tool in my clinic, but we lacked the resources to help our patients we screened. What does the state plan to do to provide services and support for patients and health care systems when we have identified those at risk?

Nadine Burke Harris: That is a wonderful question. Thank you so much. So one of the, so there are a couple of pieces that I wanna pull apart there. So one important piece is that a recognition that when it comes to ACE screening, I think that there is a belief for many folks that in order to be able to screen for ACEs, you have to have either a robust mental health resources or social work resources in order to be able to respond, and I think that one of the most important things that we can do is help primary care providers recognize what they can do in the primary care home that can improve patient outcomes even in absence of those resources, right? That’s one of the, because I actually think there’s an incredible power in that, and helping folks to understand, for example, about how we can counsel patients about sleep, exercise, nutrition, mindfulness, mental health, and healthy relationships. Helping patients understand about how early adversity affects their health and being able to support them in the hygiene that can help to improve their outcomes I think is really critically important. And just as an example, one example of that, right?

One of the places that this plays out clinically is in the management of ADHD or attention deficit hyperactivity disorder, right? One of the things that we found in our clinic is that when you look at the biology of adversity and on the functioning of the prefrontal cortex, right? Is that if you have a little bit of stress hormones, right? If you don’t have enough stress hormones, the prefrontal cortex, the part that’s responsible for executive functioning, doesn’t work very well, and so you’re distracted, disorganized, impulsive, and forgetful. And so you add stress hormones and you improve prefrontal cortical functioning up to a certain optimal point, and then if you continue to add stress hormones, executive functioning declines, right? So it’s this inverted U shape. And what’s the most common treatment in America for attention deficit? Stimulants, right? And that makes sense if you’re on this part of the curve where you need more stimulants to help you get good functioning, but if you have a child whose brain is bathed in stress hormones, then adding a stimulant may not help and in some cases may even do harm, and I think that most of us have experienced that in the sense of, oh, this patient came in, they were on Ritalin, the Ritalin didn’t work, so we added something else. That didn’t seem to work, so now they’re on an anti-psychotic, right? I can’t say how many patients that I’ve seen in that situation, and understanding that’s a place where an ACE screen, when I am going into, in my clinical practice, an ACE screen, when a child is coming in with symptoms of ADHD, if their ACE score is a zero compared to someone with an ACE screen of an eight, I actually start with different medications.

A patient with an ACE screen of zero and all of the other are meeting the criteria for ADHD, I might start with a stimulant, but if they have an ACE score of eight, I’m more likely to start with a medication that regulates the stress response, right? What’s called an alpha-adrenergic agonist like guanfacine, right? And that is, my clinical practice, how I’m using this to treat my patients differently that has nothing to do with connecting them to an external resources. At the same time, we have to deal with the real challenge and discomfort, and I’m gonna say it for whoever wrote this question, that I’m going to, this requires us to sit in a space of discomfort between the time of identifying ACEs and fully deploying a public health response to be able to fully support all families, right?

One of the things that when we, in my former life, when we created the National Pediatric Practice Community on ACE screening and we piloted ACE screening in a number of centers around the country, one of the things that we learned is that screening for ACEs isn’t just screening for ACEs. Step one, before you even implement a practice of screening, step one is to understand what you’re going to do with a positive screen, right? And so whether that is, and you don’t have to have it all in your clinic, but whether that is making a connection to a community, community providers around mental health or social work, or if it’s their community-based organizations that can provide those supports. In some cases it’s making the connections to the schools, to the education institutions that might be able to provide some resources, but figuring out what you’re gonna do with a positive ACE score I think I almost more important than the score itself because it allows you to have a systematic way of responding to any patients who are in need.

But the fact is, one of the biggest challenges is that we don’t ask because we don’t know what to do with a response, and what that means is that our patients are sitting with this, and they don’t even have us as a resource to even validate their experience. I will say the interesting thing about Vince Felitti and the work that he did as a principal investigator of ACE study as Kaiser is that he implemented adding the ACE screen into the intake at Kaiser. He did it, they got funding to do it as pilot and they did it for 110,000 patients, and they didn’t hire a single additional social worker or mental heath professional, right? And what they found, that in the following year their ER visits dropped by, and I believe it was 25%, and their sick visits dropped by 11%. It wasn’t a very well-controlled study.

However, what Dr. Felitti reports from that was that just to, it was powerful for patients to be able to acknowledge that there is a connection between what has happened to them and what’s happening in their health, right? So that acknowledgement I think is, as they say, both diagnostic and therapeutic, but in addition, that doesn’t alleviate our obligation to have systems that support and heal, and that is the work that we are doing in earnest now around how do we use our current resources? How do we look at deploying our Medicaid dollars? How are we addressing the mental health crisis in our state, and so what I wanna say to that is that work is absolutely happening at the same time.

Omonevia Abogadi: You answered so many questions within that. Next question, what kinds of interventions would you suggest for adults who have already experience ACEs?

Nadine Burke Harris: My short answer is sleep, exercise, nutrition, mindfulness, mental health and healthy relationships. And that’s just, I mean, those are some of the evidence-based interventions looking at the physiology of toxic stress. So when you have an overactive stress response, right? The changes, the impact that it has on the brain, the immune system, the hormonal systems, and the way our DNA is written and transcribed. So all of those interventions reduce stress hormones, reduce inflammation, and regulate against some of the cellular and oxidative injury that we see with toxic stress.

Omonevia Abogadi: Does ACE screening include gun ownership and gun violence? And what is the state of California doing about gun violence as a public health crisis?

Nadine Burke Harris: ACE screening does not include gun ownership and gun violence. When we use the term ACEs, when we’re rigorous to the science, we’re applying those to the criteria that were included in the ACE study by Felitti and Anda. Was it by any means exhaustive? Did they pick the magical 10 things that increase your risk for negative health outcomes? They didn’t. Although, they did have a little bit of magic in the 10 criteria that they picked, in the sense that each of these, each of the 10 criteria, do somewhat of a double whammy of being a significant stressor for the child and also taking out the other piece, which is the other criteria for toxic stress, which is adequate buffering, caregiving, right? So if your parent is incarcerated, not only are you stressed out about you’re missing your parent, but that parent isn’t there to be a buffer.

Similarly, if there’s domestic violence happening or intimate partner violence, not only is the violence stressful, but the ability of your caregivers to be a buffer to your stress is diminished. And so I feel like that’s a little bit of the secret sauce in the ACEs criteria. The reason that’s important is because when we say an individual with four or more ACEs has double the risk for heart disease, right? That gives us a public health imperative, and so looking at having rigorous relative risk data is actually really important, and when you change those criteria, then you would get a different set of odds ratios, right?

So you can’t compare apples to oranges. In terms of gun violence, what we do know is that the mechanism by which ACEs lead to negative health outcomes is this mechanism of toxic stress. Overactivity of the stress response and absence of the buffering. What we know is that when kids are, when any one of us is impacted by gun violence, that that activates the stress response and that that can also impair the ability of our buffering, caregiving systems when the entire community is impacted by a terrible incidence of gun violence. California has been a leader in addressing gun violence. So just this year, I stood with the governor as he signed legislation implementing background checks for ammunition. California has implemented red flag laws. California has really led the way. It really, kind of pushing the envelope and getting pushed back with litigation, right? On really trying to implement as much common sense gun safety for public health and public well-being that we can. One of the big challenges is that individual states can pass this legislation, but what we see is that when individuals can obtain firearms with large capacity magazines from a neighboring state, we’re only as safe as the gun laws in our closest neighboring state.

Omonevia Abogadi: Okay, what is the one thing K-12 public education should do for ACEs prevention and mitigation?

Nadine Burke Harris: Great question. If there was one thing I would say, training and education for every single individual in the educational environment around trauma-informed and trauma-sensitive practices because I believe that when we know better, we do better, and for many educators, when educators don’t understand that a child potentially acting out in class may actually be exhibiting symptoms of toxic stress, and that when we come down on them with harsh disciplinary practices rather than recognizing that we have the opportunity to be delivering doses of buffering care in those moment, right? That’s a huge missed opportunity. I feel like our educational systems have an enormous opportunity to be delivering doses of buffering every day, but that also requires our educators to understand and be practicing self-care, right? And understanding how they, if I’m an educator, my own history of adversity may be impacting how I’m showing up in the classroom. The thing about this is that none of this is inevitable. We can and we are right now implementing policies and practices that are improving outcomes for patients, for students, for individuals across sectors. It’s really about having the skills and tools that we can implement systematically to make a big difference.

Omonevia Abogadi: And for our last question, do you think you can use your position on child stress and trauma to address this administration and Trump regarding separation of children from their parents, and being on the border and caging them.

Nadine Burke Harris: This is actually one of the things about this role that I feel most gratified about because while there are really, really challenging, tragic and fundamentally difficult things that are happening right now, I’m really glad that I’m in this fight. So I think, I’m looking at my communication, can I say? Can I say? Next week? Yeah? Oh, yeah, okay, so, all right, I’m just checking. I’m trying to not get myself in trouble. I’ve never been in public office before, so then I say something. I’m like, “I gotta watch out.” So next week, next Thursday, actually, I will be testifying before the Department of Homeland Security on this very issue.

Omonevia Abogadi: Thank you so much, Dr. Harris, and I’m going to leave these with you because if there’s one thing I learned in med school, just because we didn’t talk about it in class doesn’t mean it’s not on the test.

Michael Lu: All right, let me give you three things before we close. I kind of gave Nadine a heads up that as soon as we close, we are gonna get mobbed by these requests for selfies and everything, so I gotta do these three things first. First of all, just really wanna thank you for doing this. This started, I think we were at the committee meeting and I had just found out that I was gonna become dean of the School of Public Health, and I asked Nadine, “Hey, do you wanna come and speak “at the School of Public Health?” And she said yes, and then I just recently found out that usually people pay her like $15,000. And not only is she doing this free for the Berkeley public health community, she even came in early today to spend some time with our students. So I don’t have $15,000 to give you, but we do have some presents for you. I’m going to bring up our assistant dean for strategy and external relations, Priya Mehta. A little public health swag.

Nadine Burke Harris: Oh, thank you! Thank you so much.

Michael Lu: So there is a Berkeley Public health T-shirt that I hope you will wear it proudly. The second thing, I want to make sure I invite all of you to come back on Nov. 12. It’s the 35th anniversary of the Berkeley Wellness Letter, so we’re gonna do a big celebration around that. And then, lastly, I just wanted to do a little bit of traffic copping, because like I said, like, it’s gonna get crazy pretty soon. I think there are gonna be so many people that wants to take selfies with you and everything, so we’re gonna position ourselves kinda down below where it says Berkeley Public Health, Berkeley, and she’s been so kind and generous to agree to shake hands with you, talk with you, take pictures, but certainly we have a great reception out there for all of you and hopefully, yeah, we’ll try to get as many selfies as possible.

Nadine Burke Harris: Can I say one thing before we close? I will say that, first of all, when Michael Lu invites you to come and speak, you don’t say no. Right? But what I will say is that I believe fundamentally that social determinants of health are to the 21st century what infectious disease was to the 20th century. And in my role as California’s first surgeon general, it is my intention to lay the infrastructure to ensure that we in California will cut ACEs in half in one generation. And y’all are gonna help me do it. I’ll see you at the reception, thank you.