2019 Public Health Ethics Forum: Ethical Dilemmas in Child and Adolescent Health – Part 6 of 6



it's a pleasure from each our closing plenary speaker for this afternoon dr. Stan su new dr. Sinuhe is currently currently serves as an assistant professor of internal medicine pediatrics and public health preventive medicine at the Emory School of Medicine he holds appointments within the division of general medicine general pediatrics and adolescent medicine and preventive medicine he also serves as an associate program director for the Emory J Willis Hurst internal medicine residency program at Grady Health System dr. Sinuhe obtained his medical degree at the Medical College of Georgia and then completed a combined internal medicine and pediatrics residency and pediatric chief residency at Rush University Medical Center in Chicago Illinois he did his fellowship at the Cook County health and hospital systems preventive medicine and public health program during which he also obtained his mph at Northwestern University daughter sinuhe's main research interests include adverse childhood experiences trauma informed care and addressing social determinants of health in clinical care settings in 2017 he was invited to speak at the first annual TED talk in Chicago where he highlighted the importance and need for human service institutions to have a deepened deep and understanding of the multi-dimensional life course effects of trauma and actively engaged in efforts toward trauma-informed transformation dr. Surnow is present about teaching about adverse childhood experiences and training future conventions on effective ways to address trauma and the primary care setting he holds additional training and urban primary care leadership at the University of Chicago's Lucent program integrative medicine the Center for Integrative Medicine at Northwestern University medication-assisted treatment of opioid use disorder and positive parenting practices known as the Triple P primary care please join me in welcoming dr. Stan soon [Applause] thank you for had a very long introduction captain Wilkins good afternoon it's really great to be here today it's an honor and in the weeks leading up to today I questioned a lot whether I was the one worthy to be on this stage but I think that's as I reflected on that I guess that's the appropriate tension to have from where I stand but today I want to talk about a topic that you've probably heard of at least somewhat today whether you were in a workshop or in opening sessions but it's a topic that I feel is is very important obviously relevant to what today's event is about but it's a topic that I wasn't taught about in medical school if you can believe it and without giving it away what I hope to convey in the time that I have is that this topic is so crucial and essential fundamental fundamental and foundational to our understanding of root causes of illness of disability of disease as well as trajectories of health some years ago dr. Rob Ross not not the painter but pediatrician and CEO of the large foundation out in California he was quoted as saying that of all things right of all things that childhood trauma was the number one public health crisis but not only that is it's a public health crisis that is simply hidden in plain sight we don't talk about it we keep it behind closed doors we act like it's not there and yet it is causing it has devastating consequences both to people and communities before I go on I want to say very clearly that none of this is new this is not new information and and we and and it's almost you know I want to confess even that in academia we have this tendency to intellectualize the struggle the hurt of real people of real communities and and and and that's wrong and so the point of this is not to induce some sort of armchair apathy but the data that we show is designed all of it is designed to move the needle to get us closer to advancing equity through this frame now what I will say that is that is somewhat novel that the average child experiences study brought us is that it gave us an epidemiological unit by which we could quickly in efficiently describe the long-term impact of trauma not just on individuals but of populations about a year ago when I was still in Chicago I was in clinic and it was one of my Pediatrics clinics and I saw in my schedule that there was a four year old girl and she had come in with her mom and next to her name said Hospital follow-up and before I went into the room I had a chance to look through her chart nurse what does this follow-up about and it turns out that she was seeing me in clinic for a follow-up of a gunshot wound a four year old girl and what had happened was she was on the front porch playing with her mom on a typical day and a car pulled up in front of their house and arm stuck out the window with a gun in hand and began firing in in their direction and this girl was hit in her right collarbone the bullet went through the back shoulder it took me a moment to have the courage to go into that room because I didn't know what I was gonna say to this mother I didn't know what this health system that I was a part of could offer her all I could do was look at the wound but when I went in true to my fear that I had all I could do for the first 30 seconds was just shake my head and the mom she detected this conflict in me and what this conflict was was this for me it was this realization that Here I am a health professional a physician I'm supposed to be a part of a health system that is supposed to keep daughters like her well and healthy and safe and yet I was it was it was a moment of realization that our health system was nowhere near addressing the structural determinants that allowed for this event to happen and is still allowing being things like this to happen and so I turn to this gathering today this community of public health and medical professionals and educators and students to say and this trauma informed care buzz of this movement we are actually at an inflection point a flashpoint in which we really need to anchor ourselves to advancing equity before we do anything else around adverse childhood experiences when I when I do thank you for today is is unpack three main things first what are adverse childhood experiences why do we care about them so much what kind of health outcomes are they linked with and I'll try to breeze through this and I'm sure we've heard about it today secondly I want to talk about how what's Happ what do a siz do physiologically underneath our skin that promotes disease and disability and then third what can we do about it the adverse childhood experiences or aces study is not new it was started in 1995 and the first papers came out in 1997 or 1998 so it's over 20 years old but this is considered a landmark or seminal public health study because it was a joint effort by the CDC here and Kaiser Permanente in San Diego and what these researchers did was they surveyed over 17,000 adults on their history of different types of adversity encountered before the age of 18 now these aces spend ten different categories across abuse neglect and household stress or household challenges as we call it as well and so within abuse they asked about physical and emotional or sexual abuse they asked about physical or emotional neglect and then different types of stress that one can encounter growing up in the home such as mental health problems or substance use and a family member and incarcerated relative domestic violence against the mother and then probably most weekly parental separation and divorce now before I show you what they did with this with this information what they found I want to show you who they studied because this is really important as we think about how do we extrapolate or generalize the findings from this one study to other communities and populations so of these seventeen thousand adults seventy-five percent were white seventy-five percent had gone to college 100 percent were insured so by and large this is a mostly white mostly educated middle class and up population an affluent participant group and the reason I I press on this because one of the first key finding from this study was that aces were unexpectedly common again childhood trauma is something that it's hidden in plain sight up until this point these researchers really didn't have a good idea of how common are these events in families and so what they found when they quantified the number of aces each person had they were stunned to see that about 64 percent two out of every third person in that study had one ace or more 12 and a half percent or one in eight had four or more on the flip side only 36% had a child who that was free of any of these ten categories so aces aces are something that the bottom line here is that it's not something that we can push off and deny exist within our own communities it's not something that we can say it's a problem of those communities we're gonna leave it there well this is a problem that is meaningful and it hits home for everybody the second key finding from this study and this is what kind of got me into this space as a as a pediatrician as an internist what had my jaw on the ground was that they observed an assay dose response relationship between the number of aces a person had and their risk for a wide array of negative health outcomes aces are negatively associated with health and well-being and to do this they developed what they called an ace score which simply is the total number of aces that a person has so it ranges from zero to ten is zero if a person has experienced none of these events it's ten if they experience all ten now one of our students mentioned earlier the ace score is actually a pretty crude measure it's completely agnostic to the number of perpetrators the severity of abuse or neglect the frequency if if the emotional abuse happened from one perpetrator or seven that it only count it still only counts as an a score of one but even with such a crude measure they observe from some pretty stunning associations and so what they saw was that the more aces a person had the high risk they would be for health risk behaviors like smoking heavy drinking drug use mental health problems like depression or anxiety some of the leading causes of death in the United States aces are associated with chronic disease ace is also associated in a dose-dependent manner with job challenges and having problems in school and to give you an idea of what this dose-response relationship looks like here we're showing the association between aces and health risk behaviors you can see smoking heavy drinking and drug use there and the different colored bars represent the different ranges of ace scores and what you can see is that the higher the ace score simply the higher the prevalence of that of a given health risk behavior such as smoking heavy drinking and and less commonly drug use aces are associated with mental health and a dose-dependent manner as well so they're associated with mood disorders like depression anxiety substance use problems as we just saw in the previous slide and impulse control disorders like ADHD and look at the difference between those with an ace score four or more and those with an ace score of zero aces are associated with chronic disease and a dose dependent manner as well so they're associated with ischemic heart disease which is heart attacks largely in that category stroke COPD which is chronic lung disease similar to asthma and diabetes and then finally aces are associated with this sort of other bucket of socially related domains of job absenteeism having financial problems in general and then having having trouble holding or having trouble in your job in general but in healthcare we we don't really look at prevalence so much as we care about measures of risk or measures of association so we want relative risk ratios or odds ratios and so when you compare those with four or more aces – those with no no aces you can see that for an outcome or a history of a suicide attempt the odds ratio is 12 for IV drug use 10 alcoholism / 7 illicit drug use almost 5 depression 4.5 and so on and so forth car being a current smoker over two times having a history or BMI of over 35 35 and over 1.6 again we see the same kind of dose-response relationship between aces and chronic disease so again we're comparing those with four or more aces to those with none and the odds ratio for something like COPD again chronic lung disease is almost four for stroke and heart disease over two times for cancer any cancer in diabetes over 1.5 in my own research being a clinician for both children and adults I became interested in the association between aces and chronic disease specifically within young adults because chronic disease is something that we think stereotypically happens in the middle age or in your elderly years but it's a big deal if a 35 year old gets diabetes that's a lot different from from well it's a lot different when a 35 year old gets diabetes compared to when you're 70 and get in and you develop diabetes and so what we saw among adults age 30 18 to 34 was that aces are indeed associated also in a dose-dependent manner with some of the leading causes of deaths and chronic disease in our in our country now I showed you a bunch of data on the dholtze but certainly the effects of aces can be seen in the early childhood years and so if we go back to the early childhood years and we're looking at development one study looked at the association between aces and developmental delay and found that for those children with an exceedingly high burden of trauma 7 aces or more the prevalence of a developmental delay not meeting milestones as expected approaches 100% in the school-age we can certainly see the effects of aces and I I have to say that I gave this talk a similar talk like this to bunch of school tee one time and the whole time they were just saying duh after every slide because they see this real time right and so what what one study saw was that aces are associated in a dose-dependent manner again with different types of academic risk so if you compare children with four or more aces to those with none the odds ratio for academic failure three point four for having attendance problems almost five for having school behavior problems almost seven and this is adjusted for the school attended grade level whether or not they're receiving free or reduced lunch and if they're in special education the same study looked at the prevalence of having two or more school problems understanding that it's very rare for only one domain of school performance to be affected in in response to aces and so what they saw was that 52% half of children with three or more aces have two school problems or more compared to only 12% in children with no aces with respect to chronic disease we know that children with four or more aces are at a markedly higher risk of having a diagnosis of asthma compared to children without aces so if aces are common and if they're negatively associated with health and well-being at some point we would expect an impact on mortality or change in lifespan and so this is what the same ace study groups saw is that for those individuals with an ace score of zero the average lifespan was about eighty years comparatively for those individuals with six or more aces that lifespan goes down by twenty years on average to sixty years just let that sink in a second this is in the United States a difference of twenty years the measurable difference between these two groups is the burden of trauma encountered before the age of eighteen now when you look at this list these ten categories of aces it doesn't take long to ask the question well aren't there more aces and undeniably unequivocally yes and so to talk about this I like to use this illustration which we call colloquy the Aces tree and so if you'll imagine with me that the leaves and the branches reflect the interpersonal or conventional aces of abuse neglect and household stress every tree grows out of a system of roots and so the roots are what we call adverse community environments things like poverty violence in the community racism economic disadvantage or unaffordable housing in and of themselves these are adverse events we know that these are strongly associated with negative health outcomes as well but they also provide sort of this contextual scaffolding or pressure out of which the interpersonal aces might occur at higher frequency or severity but it then just stop there roots grow or tree grows and through through drawing in the surrounding minerals and nutrients from the soil around it so in a lot of ways the health or the future of the tree is predicated on what's in the soil and so we call the soil adverse collective historical events things that have happened in recent history examples on this slide things that have conferred an intergenerational impact such as slavery forced displacement of Native Americans the Holocaust Holocaust and mass incarceration and this isn't some theory or empty heuristic or left left field you know idea if I don't have time to go into it today but the field of epigenetics is quite for me what they're finding in epigenetics is quite scary because it's what it's suggesting very compellingly is that trauma can actually be inherited across generations and we can measure that through changes in the epigenome some work done by our friends here at the CDC what they investigated the prevalence of aces across 23 states in recent years and after serving about after after analyzing data from about 250,000 adults what they found was that ace scores are indeed higher in african-americans Latin X and multiracial individuals compared to their white counterparts they're higher in those with less than a high school education who make less than 15,000 a year and who are unemployed they're also higher than those who identify as LGBTQ compared to their straight counterparts so the key point that I want to press on here that as the country starts to wake up around adverse childhood experiences as it becomes more popularized and more familiar as you start to hear more conversations about it addressing aces without addressing structural and historical determinants that have promoted and permitted conditions of adversity to to fester will inevitably lead to widening disparities and health outcomes so a rising tide lifts all boats approach will inevitably lead to widening disparities in health outcomes so that's a long way of saying that aces affect our health pretty profoundly the next thing I want to talk about is what what is underlying this relationship between aces and poor health outcomes how is this happening the first time I heard this talk in my mind this is what I put together I thought well aces must be related to disease through increasing health risk behaviors like smoking or heavy drinking or increasing the risk of mental illness mental health problems like depression or PTSD both health risk behaviors and mental health problems are independently associated with negative health outcomes while this is partially correct it's not the entire story and last summer you may have heard of in the news we may have read in the news the president of the American Academy of Pediatrics going down to South Texas where she visited some of these detention centers where they're separating families who were trying to enter the United States and she was quoted as saying that prolonged exposure to highly stressful situations known as toxic stress that can disrupt a child's brain architecture and affect their long-term health long and short-term health so this model again while it's partly correct is is incomplete and to make a long story short 20 to 30 years of convergence of research from psychology and neuroscience and biomedicine and sociology has found that there appears to be this phenomenon of toxic stress to the extent that aces adverse community environments increased risk or a toxic stress response another way you could think about what toxic stress is it's it's a hijacked stress response we were designed as human beings back in the day that when we were in the woods and we saw a grizzly bear we needed our stress response mechanisms to kick into high gear we need blood going to our lungs blood going to our eyes so that we can see clearly blood going to our muscles and all of that is mediated through a very efficient stress response that was then the problem with that is when that stress response doesn't shut off when it doesn't turn off that can lead to long-term health problems but toxic stress can affect brain development it affects brain architecture it can disrupt brain function and in severe situations severe circumstances it can actually affect brain growth as well toxic stress can disrupt our endocrine system the balance of our hormones and how they're regulated in our body the endocrine system is tightly regulated with our immune system and then as I mentioned before toxic stress can affect our epigenome I want to talk a little bit about stress because we rip on stress but not all stress is bad there are good kinds of stress that we encounter such as before before you start your first day of school or on the job studying for a big exam there's kinds of stresses that are our formative and resilience building then there are tolerable types of stress which by definition our undesired events the loss of a loved one a hospitalization but the idea is that these are discrete events they happen but the effects are thought to wane over time with enough social support in resilience built in but as I mentioned before toxic stress is in its own separate category toxic stress by definition is strong severe prolonged unpredictable if this is the kind of stress this is the six or seven year old child with a parent who might be away or incarcerated with with another parent who has mental health problems there might be abuse or neglect going on in the family there might be violence in the community that family might not have enough food left at the end of the month in the refrigerator that's six or seven aces right there where is the light at the end of the tunnel where is that straw does that child know when that stress is going to end it's this kind of stress that can profoundly change a person's physiology if it occurs in the absence of appropriate buffering mechanisms we know that in the first two years of life that there is a dramatic proliferation of the neuronal network to the extent that by age two this is this is supposed to happen for every child by age two there are hundreds of trillions of neurons in the brain but we also know that even at an early age we can see disparities in some of the most fundamental developmental outcomes in that age period so this is an old study from the mid 90s showing the number of words children know by age 3 based on their parents socioeconomic status and what you can see is that children of parents who are college-educated know way more words at age 3 than children whose parents were on welfare is that because children's whose parents were on welfare were loved any less absolutely not this is the toxic stress of poverty which we're measuring through developmental outcomes such as vocabulary as I mentioned before toxic stress affects brain function so this is a scan a brain scan which we call PET scan and it measures it it's implicitly measuring activity in the brain so the areas that show up as bright red are signaling brain activity and on your left is the brain of a child who was raised in a caring nurturing environment on your right is the brain of a child who was raised her entire life in an Eastern European orphanage and when given the same prompt to illicit activity in the temporal lobes you can see a marked difference there the temporal lobes are important for auditory processing and so you can imagine that if that area of the brain is disrupted because of toxic stress it'll affect that child's ability to communicate which affects multiple domains not just school and severe situations toxic stress can actually impair brain growth so this is a cat scan or CT scan of two three-year-old children the one on your left again was raised in a normal or nurturing environment the one on your right was raised under conditions of extreme neglect and you can you don't have to be a radiologist to see the vast difference in brain volume and the kicker is that both of these children are of similar height and weights we can't attribute the difference in brain volume to a nutritional deficiency but the most common areas that toxic stress affects the brain are in the amygdala and prefrontal cortex so toxic stress causes over activity of the part of that the part of the brain that regulates fight or flight or freeze when it does that when the amygdala is is persistently activated it actually negatively feeds there's negative feedback to the prefrontal cortex this is the part of the brain that's important for planning for the future empathy self-awareness controlling impulses behaviors and so you can imagine that for a young child if the amygdala is being constantly are persistently activated that in in it's eliciting negative feedback to the prefrontal cortex that can disrupt the development the full potential the full development of the prefrontal cortex now if we were to put all of this in one coherent model we know that there are factors at play that are that are affecting trajectories of health and wellness that are that are occurring well before conception in the form of adverse Collective historical experiences adverse community environments and then after a child is born aces can occur aces as we just unpacked before can disrupt neuro development and the stressed brain we all do this the stressed brain will we'll find ways to soothe itself we'll find ways to cope the problem is and this is one of my favorite quotes from dr. felitti who was one of the principal investigators of the ACE study he said once it's hard to get enough of something that almost works and I and I can think of no better example of this than nicotine nicotine and cigarettes nicotine is actually a very strong eggsy oolitic it helps to bring down stress and anxiety it's just that a it's very very short-lived be it's highly addictive and then see it's it's in cancer-causing sticks so it's amount you know so there are a lot of reasons you shouldn't do it but does under you know now I'll never forget how how this understanding this kind of what we just went through in the in the neurobiology of trauma change my opinion of how I address smoking cessation in the clinical encounter I don't ask patients anymore are you ready to quit smoking instead I ask how does it help you and how can I help that which you find you need to go into cigarettes to reduce your stress of course coping or maladaptive coping and adoption of health risk behaviors is a set up for disease disability and early death now if I were to show if I were to consider our health system as an iceberg and we're really addressing things that we can see above the water surface we're really not addressing things beneath the the the water surface I would put that that pyramid there if you're sick if you're actively sick or acutely sick America is actually a pretty good place to be compared to the rest of the world we have the best acute care so it says we have the best acute care in the world in this country but what are we doing for all of these other levels all these other opportunities to intervene and prevent things from happening prevent things from escalating to the point where you need acute care I know we hear a lot in our media about a school to Prison Pipeline but I hope I made the case that the problem that we're seeing is actually bigger than that I think what we're seeing is a trauma to school to Prison Pipeline kids are passing through a home passing through school even the Health System on the path and them in the pipeline to prison we have to do something about this so what I want to finish up with and if I can go to 405 if that's okay with you I want to say that there's good news and I wouldn't be up here talking about this if there wasn't good news around this and a lot of what we know about what to do is actually it derives from even in this room right even in this very room there are there is a good number of people we extrapolate what we learn from the original ace of study to this room there's at least two out of every third person with an ace or more at least one out of eight people having four aces or more and yet for those who have gone through a significant burden of adversity when you're in your youth you you're the fact that you're here to me indicates that at least some measure of success some measure of resilience what is it about you or maybe it's a family member or a friend that comes to mind when is it about you that allowed you to succeed that gave you the chances of success in the face of adversity well I know this is a tired word now but it does mean something in the operative word is resilience it's this at least through through the perspective of trauma it means the ability to adapt and succeed in the face of adversity but the important thing about resilience is that it can convert what could become toxic stress back into tolerable stress it allows people to bend but not break and the essential thing about resilience is that yes people are born with a certain kind of temperament you might have a proclivity to be more anxious or not but resilience is not something that anybody is born with resilience is built through a child's interaction with their his or her environment and so one way to think about how to actualize resilience is a simple seesaw in which in the face of negative factors that could pull away from resilience if we can stack more on the positive side in the scale tips towards that end you can actualize resilience so what are these protective factors that we're talking about well the one that I want to press on hard and this is the game changer is having a strong stable for a child to have a strong stable nurturing relationship with an adult caregiver it doesn't have to be a parent it doesn't have to be a family member it just has to be an adult who's willing to walk in a child's life through thick and thin over a long period of time this is the game changer it's necessary not always sufficient but it is absolutely necessary a second important protective factor is learning for ourselves and for our communities and self-regulation skills and there's been an explosion of research in the last 20 to 30 years from neuroscience trying to get at how do we are there ways that we can regulate our own brains when we feel when we're feeling distressed or stressed or anxious other ways that we can calm down our own amygdalas the third piece which obviously relates to the first one is having a meaningful connection with multiple adults in the community the negative factors or things that we already talked about poverty exposure to violence maltreatment etc but the bottom line for this point for this part that I want to highlight is that aces are a risk for negative health outcomes not a guarantee where adversity can harm us resilience can protect us relationships protect us and going back to the story that I told the beginning of the four-year-old girl I didn't say when I walked in the room the girl was sitting in her mom's lap and as I walked in the room they were looking at each other they were looking they were facing each other and they're actually finishing up a song they were singing together and throughout that encounter what I learned was that the girl had had an understandably rough time but she was doing better each day and the mom said very clearly me clearly to me that she was gonna be there that she had a strong bond with this child that she wasn't worried that this child was gonna be okay and I left the room feeling somewhat relieved all I did was observe resilience in action that's simply all I did and this leads me into talking about this this framework of trauma-informed care trauma-informed care is not a list of activities it's not a list of things to do it's a perspective it's understanding we take when we talk about care that is trauma-informed we're talking about a framework that is grounded in understanding how trauma affects us and then what we can do and response to that how do we treat each other when you look at a photo like this people waiting for the train who has experienced trauma how can you tell well it's a rhetorical question because we don't know trauma doesn't show up on our skin it doesn't there's no mark on our forehead like a Scarlet Letter and so this begs the question well if trauma is common then what is the way that we should treat each other what is the way that organizations should treat their clients in response to what we know about trauma and so that the critical paradigm shift that we have to have an understanding what this trauma-informed movement is all about is when we see a friend or a colleague maybe it's a family member exhibiting behavior that we would consider self-destructive or problematic that we resist that knee-jerk impulse to say what's wrong with you and instead we ask openly what's happened because here's the rationale if trauma is common if it's associated with a wide array of undesired health outcomes if our our response to stress a lot of times is maladaptive then saying what's wrong with you to a person who's experienced trauma could be so marginalizing when they never asked her that trauma to happen to them in the first place as you think about how to become more trauma-informed there are a number of principles that are worth considering and the first one is building awareness and I think we've done that a lot today through through through the different workshops and events of today but you don't know what you don't know and I believe in this situation that that knowing the long-term effects of trauma is power the second piece and I want to camp out here for a little bit is this notion of promoting safety because safety for a person who's experienced a significant burden of trauma safety is not something that is taken for granted and it should not be assumed think about so I can use my studying as an example in the clinic if I'm sitting across a patient and they don't feel safe in that environment that means that there are Magdala is on if their amygdala is activated there's negative feedback to the prefrontal cortex that person as long as they don't feel safe is not in a posture or position or disposition to learn to make informed decisions about their health to make decisions that they would want to make on behalf of their own bodies so we have to examine how we how we think about safety not just in the physical environment but in the culture of the staff in the culture of the organization at large trustworthiness and transparency are essential pieces of trauma-informed care simply because many who have experienced trauma have had broken relationships with the very people they were supposed to be able to trust and so Trust cannot be assumed in any encounter with a client or a patient we have to actively work to build trust and a lot of times that count that the first step is acknowledging wrongdoing that's the first step client autonomy collaboration and new ality are important concepts as well and the way I think about this is that these how challenged me to always think about sharing power because again those who've experienced trauma have had decisions made for them and yet they are the ones left to deal with the consequences of that so thinking about ways to share power can be empowering and can align the provider and the client or the patient together integrating care I think is one of the most difficult principles on this list and in the rationale for integrating care is like this trauma doesn't care it the effects of trauma spanned multiple domains it's like spaghetti throwing spaghetti and meatballs on the wall and seeing what sticks if that's the case and if we want to be a health system that responds effectively and efficiently for those who are dealing with the consequences of trauma we have to find ways to reach across the aisle to be brave and courageous with with crux of collaborating across sectors so that patients aren't having to figure out for themselves a client or communities aren't having to figure out for themselves how to navigate the health system and last but certainly not least having an awareness of relevant cultural historical and gender issues is absolutely essential to being trauma-informed because simply put if we don't have a narrative understanding of our patients we're not informed but the thing that brings all this together again is that is relationships the thing that brings all of all of the trauma-informed principles together is this is the nucleus if you will is this important is the importance of relationships but this is a quote from Bruce parry one of the more leading researchers in this field you once said that the human brain we're neuro biologically designed for relationships but we have invented contexts that are relationally impoverished and here's the irony right all of the data around adversity and resilience is saying we need to anchor ourselves we need to double down more than ever on the importance of cultivating healthy relationships at an early age and yet the direction that our society seems to be moving with the advances in technology seem to be antagonistic to that end and so we are swimming upstream here well that being said as we think about the solutions and what we can do and this is really a high-level point of view but there are so many levels of opportunities stemming from the individual to the community all the way up to policy solutions I think a useful guiding principle a North Star if you will is this idea of systemic empathy what I think systemic empathy is is it's the integration of the science of trauma with a relational focus on understanding people understanding humans and building in a space for people to be human it doesn't mean that for a given organization a group of people that nothing else matters but yet again it's it's a guiding principle it's an evidence-based rationale for prioritizing relationships and connection and understanding and as a mental exercise right let's take the example of a of a 15 minute visit with your doctor in primary care right and think about the ways that 15 minute visit is is justified you might think you might hear it's about finances about reimbursement it's about volume throughput sometimes you might even hear do you need more than 15 minutes to address a person's problem and write a prescription and have them on their way right but through the frame of trauma through through what we know about from adversity a 15-minute visit could actually induce harm how can you build trust how can you build autonomy how can you ensure safety when you're only seeing a person for 15 minutes and asking them to leave your clinic I am going to jump ahead since I'm running short on time here so one more time going back to the to the to the four year old girl that I was talking about earlier sure I left the exam room relieved and I I thought wow there's there's just an amazing connection there between this girl and her mother but the fact remains she was still shot and the fact remains that she was still living in a neighborhood in the southside of Chicago with high rates of violence with with economic disadvantage that fact is still there so if we were to think about if we're thinking about how do we prevent things from this things like this from happening how do we advance equity I would argue very strongly that we have to go as upstream as possible and this is a slide that I borrow from the essentials for childhood initiative showing a list of a non-exhaustive list of policies that have shown to work shown to improve the health and well-being of children but they're heterogeneous Lee applied across different states what would it look like in Georgia if we got together and advocated at least for some of these solutions some of these policy solutions each of these examples not only addressed aces or adverse community environments that disproportionately affect neglected communities but they also helped cultivate environments and opportunities for relationships in the family and in the community we have to think about prevention I would say we have to think about prevention first as a response to what we know about the long-term effects of trauma as I close I know the idea of preventing aces sounds lofty and it's it's hard to even imagine right what that would look like sometimes but photos like this remind me to have hope this is a photo of my grandfather who was a lung specialist he's a pulmonologist and this is he served in the Korean War and this is taken in his office shortly after the war ended and you can see he's sitting there in front of an x-ray on the screen and in his right hand there is a cigarette and we think it's ironic and kind of funny and a little sad that he's holding a cigarette but there was a time not too long ago when when the lung doctor could hold us in smoke a cigarette and it wasn't considered ironic funny or sad and we've come a long way in and we've prevented a lot of unnecessary deaths from cigarettes as the as the incidence and prevalence of cigarette smoking has decreased so my hope is that one day 30 40 years from now that will look and and we'll find it ironic and a little sad that we were a health system that did very little to address the structural conditions that permit adversity in context of trauma that's my hope as I mention at the beginning of this talk I I said this topic is not in you it's not in you and we would do well to heed the words of great thinkers before us and this is one of my favorite quotes from Frederick Douglas it's easier to build strong children than it is to repair broken men thank you for your time [Applause] thank you dr. Sinuhe I think we would like to have probably time for at least one or two your questions that was a very informative presentation so anybody has any questions go to the mic or read your hand okay I have a question oh my yeah me all right no go ahead hi I'm Courtney I'm from the minority health health equity office I'm a no rice fellow so first of all thank you for the amazing presentation as somebody who studied neuroscience I wanted to get your perspective oftentimes when we studied like playing plasticity in resiliency as well as knowing some work in healing justice in terms of that kind of activism how do you think that plays a role and sometimes the criticisms for trauma informed care and kind of asking that question of what happened to you but going beyond just people being dissed their trauma and kind of focusing holistic care in that aspect are you can you can you clarify what you mean about some of the challenges around trauma-informed care with respect to neuroscience yeah there's been I I know from studying like positive psychology and positive neuroscience folks have used trauma-informed care to understand an intersection between risk and resiliency like studying neuroplasticity but there's also been criticisms about trauma-informed care being just space too much and you're nothing but your trauma versus looking at the holistic picture kind of what you talked about so I wanted you to speak more to that if you could yeah so that's why I think you know the it can become quickly convoluted talking about resilience in neuroscience and and so I think the the precursor to it all where it is strength space is giving opportunities to optimize healthy relationships that does a lot more than we I think we know fully that does wonders for the brain in more than more ways than I think we'll ever know to be honest with you and so I would I would for me I'm not so anchored into the the necessarily the negative effects of trauma unless in the certainly in the absence of talking about how how much more and more strongly resilience protect us I will say that the the danger for me in kind of talking about resilience is that it's hard it's hard to talk about resilience in at the level of a community or a population and and that seems to be where the lines of structural disadvantages are drawn and so I think for me what makes sense is to if we address some of these structural conditions structural inequities then that will that would permit conditions or resilience to naturally follow as long as we can help optimize conditions for relationships to form I hope I answer that question somewhat yeah thank you thank you yes you're actually leading into the question I wanted to ask coming so you're you're positing some very compelling or at least pointing to possibly some compelling practice models with that are counter to the economic incentives that are driving health care right yes and so I just wonder what what do you see is the necessary direction that health care needs to take it's gonna have a less detached and sort of categorical approach to health care absolutely where to start right I think we're in this phase right now where at least in the sphere in a space that I'm in in the hospital I am I am battling trying to get clinicians to care about this right I am battling people saying this is not my job this is not what I was trained to do and and so my counter to that is to say well look at the WH OHS definition of health and we're in how much little space how much little is written how little is written about disease management right we're supposed to be keepers of health we're supposed to be healers but also people who help help communities and Families stay well and so that's my my challenge when I when I give this presentation in the hospital to really compel clinicians to think brought more broadly and have a public health frame and that's why when I when I went and got my mph I thought I found my people because I could you know I can't I was just banging my head against the wall and I kept hearing that's not your job stand that's on our roll stay in your lane but this is my lane and and and so I think you know that's two step one but secondly kind of a bigger goal is we have to challenge the the top-down flow of economics in our health system has no place with with a capitalist structure in healthcare we can never move the masses towards a system that is yeah towards a system that actually cares and would take take issues like this seriously it's not there I had a question yes we're grappling a bit with the whole issue of screening for social needs so on one hand it seems like a way to get people in the space of considering the circumstances and the structures on the other hand you know as you mentioned the the problems can't be solved at the individual level so what are your thoughts on the value of screening for social determinants of health in the healthcare setting yeah thanks for that question so I was a part of a pilot study in Chicago for institutions where we developed a screening tool and we distributed it in four clinics for Pediatrics clinic in Chicago and the long story short my opinion on it is I think there's a couple cautions that we have to have I see the upside in it I see the advantage of being able to if a child has been exposed to adversity and they don't yet have any clinical manifestations of it that we can intervene and address when the social needs of the family I think that's great but I worry that a Health System will be satisfied at stopping there and then it's kind of a hand wave at this movement when the problems go way deeper so I think that there is a place for screening there we still need a lot more data around does it work and and what are the best community resources to link with to make it work but the bigger picture for me is I I want to I don't want to stop there and and I feel like there's a danger right now of health systems who are engaged in this work being satisfied with stopping there that's my fear as well yeah Stan awesome presentation just love hearing your energy and your enthusiasm in the space and to be honest we've long needed health care to step up here right and I just want people to know that there are some resources that we've done so if you don't know who I am I'm Melissa Merrick I lead a lot of our aces work for CDC for the past seven years and we have two trainings that are online now ace online trainings one for pediatricians that we've partnered with aap to create and one for behavioral health practitioners with we partnered with the American Psychological Association on that but it's really getting at this kind of sentiment where what is your role in your profession in primary prevention of early adversity not in screen and treat or screen and referral services that's important we're always going to need that kind of work but as invoking something that dr. Hodge said just because there's a clinic in your community doesn't mean that you can get there that you can take off a work that you can actually afford to go there so that's not really giving access right but what are the many many roles that we all have to play in preventing early adversity in the first place so I just wanted to to say publicly that there are tools but thank you so much for your leadership in this space we've long needed a voice like yours and so happy that you're at Emory and we can work together hey hey thank you so much thank you can [Applause] I'm gonna dr. Hodge can you come forward please and then dr. Warren and dr. the library for your concluding remarks we have a quick special recognition for dr. Hodge and also dr. sinew by our dr. lockberg so dr. Sinuhe on behalf of the office of minority health and health equity and the Centers for Disease Control and Prevention and the fifth public health ethics forum we'd like to give you the certificate of appreciation [Applause] and dr. Hodge who we are privileged to work with throughout the year thank you for your presentation today for your ongoing commitment to this work I just want to make a quick announcement as I mentioned early in earlier housekeeping occurred each of you to please call 9/4 our to do the evaluation we really appreciate getting this on honest feedback from you as we move forward in the planning of future forms like this thank you so again I get the pleasure and the privilege of just kind of concluding our time together today along with dr. Warren and so we in the fifth public health ethics forum wiser with new connections I hope I think we've been exchanging business cards and other things and we also leave with preview the unexplored perspectives on what is needed to reduce largely preventable health disparities that are experienced by youth and particularly youth of color dr. Warren reminds us that public health ethics doesn't necessarily answer the questions but questions the answers and so I want to just think first of all our student panel thank you for sharing yourself with us thank you for for your candor and and this was it was completely unrehearsed I mean that you all were able to speak from your heart and from your experience and really enlighten us in some very powerful ways I want to thank dr. Hodge for grounding us in a framework of bioethics ethics philosophy and praxis there's so much more for us to learn before we can fully engage theories of ethics in our work but our learning journey has begun and we commit to continue to carry that forward many thanks to our breakout session presenters who delve into a variety of health issues and who helped us illuminate the relationship between like well in one of the sessions I was in we talked about the relationship between social realities like omnipresent violence and tensions between diverse belief systems that can collide in the public health decision-making process and so thank you so much to dr. Riggs for for taking us down that path and certainly to dr. Sanu and who elaborated what toxic stress is and how it disrupts healthy development and long term well-being and why an ethic practice of Public Health will seek ways to mobilize a societal strategy that will protect children and secure them on a path to a future that it's filled with hope and possibility I want to say to everyone here please take all of what we've learned today back into your workplace back into your community taking home as as well as in your personal reflections why do we do what we do in public health and how can we do it better and how can we Center the faces the stories the beauty and the struggles of the people we serve so let's keep this conversation going stay well and thank you for spending the day with us I know everybody's ready to go so I'm not gonna say very much but first and and and opposed to saying I want to thank you which is something I like I want to do no I'm just gonna say thank you straight up for being with us I was quite impressed with what doctors in new cities and I found my people okay and and that's important and for the students here you hear all this big stuff about the Centers for Disease Control and Prevention this big wonderful place it does wonderful things for the world I hope you found your people here too because they're here and if you didn't know it then you should know it now cuz they're right among you they are who you are not who you want to be but who you are so find your people and then ask them how they got where they are because what they're really waiting on you is to come and do what you have to do they want you on their shoulders because they are doing what they have to do now but you have to do what they can't do so find your people and you don't have to be in the back and I just didn't have the energy to tell you to come down to the front again but just you have that right to be in the front that responsibility to be in the front so never slow up from getting in front those seats have your names on Dhokla Burt has both energy intellect and courage into energy intellect and courage it takes all three you know you can have energy to do something and and that's just being busy you can have the interests intellect into energy to do it the intellect to do it but it takes the courage to make it happen and it's subtle but it's real we've had these for five years and not because everybody wants it to happen but because they're supposed to happen they need to happen and last and most importantly you know you heard the notion of doing the right thing and doing things right doing the right thing and doing things right will the science before us can teach us shows us how to do things right and it's some of the best science in the country in the world is right here up is up in here for 20 years good science good science raising this scientific question and answering most of them and in fact what happens when you answer the question is all punch another question to come up and that's the power of it not that you answer the question but you raise new ones but more important than doing things right it's doing the right thing you know and and Spike Lee y'all know that name what did he say doing the right thing right or doing things right it's a balance so you have to do them both this is a beginning of something that is continuing we want this to last for one day we can have it for a week but one day because it leaves you with more energy to do something on your own this was a prompt to do something on your own and what we're gonna do is next year see what bubbles up we don't know what we're gonna do next year but I tell you what it's gonna be better than this year I promise you that cuz we got the right people and we started last year with the elders and they they were off the chain but you young folk all nine unbelievable no no no believable and we want you to do more and do better don't want to start thanking everybody because I'll leave somebody out but if you did but you were supposed to do you did the right thing and you really thank you and we appreciate your presence thank you [Applause]

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