California Surgeon General Puts Spotlight on Childhood Trauma

In a CHCF interview, Nadine Burke Harris explains how she will approach her newly created role

Dr. Nadine Burke Harris, California's first surgeon general, in her San Francisco office. Photo: Michael Short
Nadine Burke Harris, MD, MPH, California’s first surgeon general, answers questions in her San Francisco office. Photo: Michael Short.

In January, two weeks after taking office, Governor Gavin Newsom appointed pediatrician Nadine Burke Harris, MD, MPH, as California’s first surgeon general. Burke Harris is known nationally for her work serving the Bayview-Hunters Point neighborhood of San Francisco, a historically Black community with high rates of poverty and violence, and advocating for children exposed to trauma.

In 2012, she founded the Center for Youth Wellness, a national organization that raises awareness about the lifelong impact of adverse childhood experiences (ACEs) and trauma on the health and mental health of children. The concept of ACEs first emerged from a 1998 study that found that children exposed to abuse, neglect, and other negative experiences had an increased lifelong risk of many common chronic health conditions. Burke Harris has pioneered the development of screening tools to assess children’s exposure to ACEs and to treat them. Her TED talk on the effect of trauma on children has been viewed more than 5 million times.

Her book, The Deepest Well: Healing the Long-Term Effects of Childhood Adversity, was published last year. Burke Harris graduated from UC Berkeley and earned a medical degree from UC Davis. After earning a master’s degree in public health from the Harvard T.H. Chan School of Public Health, she completed a residency at Stanford University. She lives in San Francisco with her husband and their four boys.

Burke Harris sat down with me recently to talk about her new mission. The interview has been edited for length and clarity.

Portrait of Dr. Nadine Burke Harris, California's first Surgeon General, in her office overlooking San Francisco City Hall
Nadine Burke Harris, California’s first surgeon general, in her state office overlooking San Francisco City Hall. Photo: Michael Short.

Q: How do you and the governor define your new role?

A: It’s a wonderful opportunity for me to be a partner and adviser to the governor and a health champion. I work in partnership with the secretary of Health and Human Services [Mark Ghaly, MD], and my role is to get out there, work across systems, engage with ordinary Californians and with the medical community, and advance the health of Californians.

Q: How do you want to use this bully pulpit, and what are the big messages you want to communicate to the state’s health care workforce and policymakers?

A: The [US] surgeons general in the past who have been impactful have been able to move the needle on specific public health threats. I don’t see this as a role of doing a little bit of everything. Governor Newsom has a strong focus on health and the health and well-being of children. That’s part of the reason we see a pediatrician in this role along with my background in adverse childhood experiences and toxic stress.

I believe strongly that adverse childhood experiences and toxic stress constitute the major public health issue of our time. Toxic stress is essentially the germ theory of the 21st century, and we implemented everything from vaccines to pasteurization of milk to sanitation of our water supply in response to germ theory. Childhood adversity leads to long-term changes in the structure and function of our brains and bodies, and those changes can subsequently impact educational attainment and risk of violence or incarceration. They dramatically affect health, with significant risks for the leading causes of death in California, including heart disease, stroke, cancer, and Alzheimer’s disease.

For many of us, there’s medical care and there’s mental health, and they’re totally separate. But the body does not make that distinction.

A public health response requires not just early identification, such as routine screenings and early intervention within the health care space. It also requires that we look at how we’re doing our work in the educational field and in our justice system. I intend to do a deep dive on toxic stress and how it impacts health, and what we can do across systems, particularly from a health equity standpoint.

For the health care workforce, a big part of my effort right now is supporting implementation of AB340 the law that requires all individuals on Medicaid, children and adults, to be screened for adverse childhood experiences. We’ll be implementing AB 340 next January. We’re moving forward pretty quickly, and the Newsom administration has allocated $45 million in the proposed budget to reimburse providers screening for ACEs. There’ll be a billing code so they’ll be able to get a supplemental payment on top of whatever they would already have gotten for that visit.

Q: Are you seeing any concern or hesitation from the pediatric community?

A: I’m starting off my tenure as surgeon general on a listening tour of California. I’ve been in Sacramento, Orange County, Fresno County, LA County, Long Beach, San Francisco, and Oakland. I visited Butte County, which has the highest prevalence of adverse childhood experiences of any county. It also recently had the severe community trauma of the wildfires.

The thing that’s most surprising to me is how welcome this change is. But there are hesitations. Providers worry they don’t have adequate resources when they face a positive ACEs screen. It indicates a need for provider training. Part of the reason for moving toward universal screening is that for so many children and adults, the history of ACEs is not recognized. Every provider can understand that the health condition in front of them whether it’s headaches or abdominal pain may be stress-related. An ACEs score reminds a provider to help their patient understand how stress impacts his or her health and what to do about it.

Q: I’m guessing one hesitation may be: “Well, even if that’s so, where am I going to send these patients?”

A: That’s a really common question. There’s a lot we need to do to support our systems and make them more robust. When Vincent Felitti, the co-principal investigator of the ACE study, began screening for ACEs, he did a trial where he implemented the ACE question into the intake at Kaiser for 110,000 patients. They didn’t make any changes to their mental health or social work infrastructure, yet there was a significant drop in ER visits and in outpatient sick visit use. For many patients, it’s just having a medical professional make that connection and say, “Your history of adversity may be impacting your health.” We need to strengthen linkages between our mental and behavioral health systems, to improve access and coverage.

For many patients, it’s just having a medical professional make that connection and say, “Your history of adversity may be impacting your health.” We need to strengthen linkages between our mental and behavioral health systems, to improve access and coverage.

Q: So how do you break down the silos and integrate those services?

A: Access and the ability to share information between primary and behavioral health care providers are key, but it also requires a fundamental frame shift. For many of us, there’s medical care and there’s mental health, and they’re totally separate. But the body does not make that distinction. Many places are moving toward integrated primary care and behavioral health and team-based care.

Q: California has been leading the effort to improve maternal health and in the last few years has cut in half the rate of women dying in childbirth. But there’s still a huge disparity, especially with Black women.

A: The work on maternal mortality has been admirable, and it shows what happens when we systematically tackle a preventable health problem. But as we look at disparities that persist, I’m asking: Is this another place where toxic stress plays a significant role? How does cumulative adversity over the lifetime affect perinatal outcomes? We know women with higher ACEs have greater risk of chronic health problems cardiovascular disease, diabetes, mental health concerns, greater risk of depression before you get pregnant, higher likelihood of being in unsafe relationships, being victimized, and experiencing physical or emotional abuse. Women with higher ACEs have increased risk of preeclampsia.

The experience of discrimination can also contribute to the toxic stress response. Combine that with the different quality of care sometimes provided for communities of color, and there is a tremendous opportunity to view maternal mortality, particularly in the African American community, through the lens of toxic stress and to address some of the root causes.

Q: What is your strategy for ensuring you have the greatest impact as surgeon general?

A: Surgeons general who have been successful have really focused on moving forward one issue at a time. Classically, it’s C. Everett Koop and the work he did on tobacco in the 1980s during the Reagan administration. It took a lot of moral courage to do the work he did, to get people to really grasp the health risk around cigarettes. That was a big deal, and there was a lot of resistance. So coming into this role, my first surgeon general’s report will be on ACEs and toxic stress in California.

Q: When will that come?

A: I hope to have it out in 2020. Being the first surgeon general in the state of California, there is some basic infrastructure stuff that needs to happen first. Like, I don’t have a printer. Literally, right now I’m printing at home. Some time after I get a printer, we’ll have a surgeon general’s report.

Q: Final question. What’s your overarching message to policymakers and folks in California health care?

A: I believe a public health-scale intervention around adverse childhood experiences and toxic stress is going to be the biggest public health advancement of our time. I want folks to be educated about this issue and to support the implementation of routine screening, early detection, and early intervention, because the evidence shows that’s key. A lot of people have the sense of: “How can we screen? It’s so difficult and expensive to treat. We don’t have sufficient resources. We’re going to overwhelm the system.”

Right now, our system is only set up to detect toxic stress when it’s the equivalent to stage four. With breast cancer, stage four comes with a much lower survival rate than stage one. Treatment is more expensive, more intensive, and much more costly. The answer to many conditions is to move detection to stage one. The survival rate for stage one breast cancer is greater than 90%. Screening is not the thing you don’t do because you fear being overwhelmed. It’s the thing you have to do so you can intervene early and prevent the development of stage four.

Q: Actually do prevention instead of mopping up later.

A: Which is far more costly, and there’s a lower success rate. So let’s do it early on.