September 24, 2020

Mental Fitness For Resilience Campaign – The Trauma of Racism

– Welcome.

I'm Dr.

Patrice Harris.

I'm a pediatric psychiatristhere in Atlanta.

I completed my Residencyand Fellowship training in child and adolescentand forensic psychiatry at the Emory UniversitySchool of Medicine.

I just completed my termas the 174th president of the American Medical Association, and I'm the first African American woman to hold that office.

I am certainly honored tomoderate this panel today as part of the partnership between GPB and Resilient Georgia and this is part of the Mental Fitnessfor Resilience Campaign.

Today's panel will focus on health equity, racism and resiliency.

And I am so honored to be joined by three distinguished panelists.

Dr.

Terri McFadden isa general pediatrician and professor in theDepartment of Pediatrics at the Emory UniversitySchool of Medicine, she is also director ofPrimary Care Initiatives with partners for Equity inChild and Adolescent Health.

She is currently the presidentof the Georgia Chapter of the American Academy of Pediatrics.

Her academic and professional interests include health equity, comprehensive care for the underserved, childhood injury prevention, brain development and medical education.

Dr.

Gene Brody is Regents professor and director of theCenter For Family Research at the University of Georgia.

The Center For FamilyResearch has been named a center of excellence by the National Institute on Drug Abuse.

And then the last two yearswas given the advances in Culture And DiversityIn Prevention Science Award by the Society For Prevention, Research and the President's Award of distinction for innovative team science from the Georgia Clinical andTranslational Science Alliance.

And last but certainly notleast, is Dr.

Stan Sonu.

Dr.

Sonu is an assistantprofessor of internal medicine and pediatrics at the EmoryUniversity School of Medicine.

Again, hope you noticethe Emory thing today.

And he also serves as anAssociate Program Director for the Emory InternalMedicine Residency Program.

Dr.

Sonu obtained his medical degree at the Medical College of Georgia, completed his residency incombined internal medicine and pediatrics at Rush UniversityMedical Center in Chicago, and did a fellowship at the Cook County, Preventive Medicine andPublic Health Program, during which he also obtained his MPH degree at Northwestern.

His research interests include addressing and preventing adversechildhood experiences and integration of trauma-informed care and clinical practice.

And I forgot to mentionthat Dr.

Gene Brody also has an appointment at the Emory University RollinsSchool of Public Health.

So Dr.

McFadden, let me start with you.

Talk a little bit about racism and how racism can be or is not.

I'll wait to hear your opinion and Adverse Childhood Experience or ACE, we hear a lot of talk about that, how that relates to toxic stress? – Thank you, Dr.

Harrisand fellow panelists.

It's a pleasure to be here this morning.

So we know that racism is acore determinant of health and leads to lots of social inequities, but independent of the social inequities, racism can be an adversechildhood experience.

And, you know, as myfellow panelists know, there's been a lot of talk about ACEs or Adverse Childhood Experiences as the adversity, the scienceof adversity has developed.

And just to give a quick a capsule view of adverse childhood experiences, the science tells us that traumatic events that children experience early in life not only affects theirpsyche or their psychology while they're young, but itreally can predict long-term physical and mental healthconsequences for those children as they progress into adulthood.

So it's not just a pediatric issue.

It's an issue around thewhole life trajectory.

And so the way that we believe that these adverse childhoodexperiences manifest is because of toxic stress.

Now, there's a lot of work(indistinct) about trauma and stress and it's hardsometimes to separate out, you know, all the thingsthat we're talking about.

But stress in and of itself isnot necessarily a bad thing.

The center for thedeveloping child has come up with a framework around stress, where they talk about positive stress, tolerable stress and toxic stress.

So positive stress is when a child falls and a loving adult picksthem up, dust them off, and they find out that yes, they can cope, they can deal with it.

Tolerable stress may bea little less normative.

These are not normal experiences.

It may be significant, like the death of a parent, or a natural disaster, but again with a loving adult, a safe, stable, nurturing environment that child recovers, develops resilience and understand coping mechanisms.

And so it can be valuable to them.

They learned that they canget through a bad situation, but with toxic stress theexposure to trauma is unrelenting and severe, and there's acouple that with there not being a loving adult, a safe, stable, nurturing environment to mitigate that stress, that child experiences an elevation of theirfight or flight hormones, which can affect brain development, particularly in the partsof the brain that have to do with executive function, which is a way that we learn, but it also affects the immune response and the immune system.

And even more, I thinkconcerning is the genetics, what we described as epigenetics, the way that genes unfold.

So this can not only affect the child in their early childhood, in their brain development, but their lifelong trajectory of health, as well as it can be intergenerational, not just from the social inequities, but from actual changes to the genome.

So this is a significantissue for children and racism clearly is one of those ACEs, even though it wasn't included in that seminal study that looked at 10 exposures that children can have, if you look at more of a community experience, weknow that racism is clearly one of those communityexperiences that can impact a child's brain developmentand long-term health.

– Great, thank you.

And Dr.

Brody, pick upon that a little bit and talk about racism and howit can affect again, life, long health, particularlyaround chronic diseases.

– Sure.

It's great to be here this morning.

And Dr.

Harris, thankyou for all you've done to promote the health andwell being of all Americans.

– [Patrice] Thank you.

– Our work focuses onchildren and families in the southeastern United States.

Those states that beginwith North Carolina, South Carolina, Georgia, Mississippi and Alabama, and if we look closely at theepidemiology of what it's like to raise a child andgrow up in those places, it can be very challenging, particularly if you're a black person.

The poverty rates are amongthe highest in the nation for black children and families, and over half or nearly 60% of black children in theseplaces grow up in poverty.

And what's remarkable is thatdespite this epidemiology, so many black children growup to be competent, healthy, and have good mental health.

If we look though, at the epidemiology, or the prevalence ofchronic disease at midlife, we find that children whogrow up in these places are 30% more likely tohave chronic disease, by chronic diseases, I mean, heart disease, diabetes, hypertension, stroke, and even dementia.

And the prevailing view has been that these diseases appear at midlife.

And actually, we take adifferent point of view on that.

We look at and believe that the origins of these chronic diseasesbegin in childhood, early childhood, andmaybe even before birth.

An important contributorto the development of chronic disease is webelieve that across childhood, children are exposed to racist encounters, and those racist encounterscan change their biology in a way that makes it morelikely that they'll develop chronic disease whenthey do reach midlife.

And this is important froma prevention point of view because if we canintervene during childhood and develop shieldsfrom racist encounters, we can promote the health ofchildren, and their children.

So we set about tofigure out if encounters during adolescence somehowchanges children's biology, adolescence biology, sothat they become more likely to develop a chronic disease at midlife.

And this was no easy feat, and we started about 10 years ago.

And what we did is we trackedexposure to racist events in several hundred ofblack high school students, and we follow them forthree or four years.

And then after they left high school, we collected a bundle ofmarkers of their health, including their stress hormones, cortisol, epinephrine, or norepinephrine.

We looked at the levels ofcirculating inflammation in their bodies, we lookedat their blood pressure, we looked at their (indistinct).

And we wanted to see ifexposure to racist encounters would be associated withthis bundle of health markers that together predict or wouldpredict the chronic diseases of aging later on in life.

And what we found wasindeed, more exposure to racist encounters whichcould be slurs or physical harm, false accusations from the police or for business owners orhaving a guidance counselor telling you that you're not smart enough to take a certain course orto go to a certain college.

All of those things overtime together, predicted those markers that wouldindicate at midlife that these young people would indeed experience chronic disease.

An important thing we found, though, was that there was asizable minority of youth who were exposed tothese racist encounters and yet did not show elevationin these health markers that would forecast for health later on.

And this is a very importantroom to understand.

– You know that that is critical.

I get that question alot about resiliency, particularly now with COVID-19 and people ask if Ipredict a mental crisis.

And certainly it's no way toknow if there will be a crisis, however, we define that crisis.

So it's not inevitable, though, but we need to get whatwe need to do right now.

And one more point and thenthis leads to Dr.

Sonu, is I'm so glad that youtalked about poverty.

And certainly, that's oneof those social determinants of health that, again, has been driven by larger structuraldeterminants of health, such as racism and biasand all of those things.

But you also separated outracism as its own independent variables, because I think weknow just across the spectrum, we certainly don't havetime to go into it today.

But no matter your economic security, you can still be affectedand impacted by racism.

And I think that's one ofthe reasons we are thinking that even African Americanwomen who have insurance and have some economicsecurity are still are impacted by the statistics aroundmaternal mortality.

So I'm so glad that you'relooking at these independent variables, because fartoo often people think that there has to bean intersection there.

And so, Dr.

Sonu, you'vedone a lot of work again, speaking of racism and biases, and how these show up in healthcare.

So say a little bit moreabout what you can teach us about these biases in healthcare.

– Well, thank you so much, Dr.

Harris.

It's an honor to be here andto be a part of this panel.

Thank you for that question.

I think what I'll start withis to just make the point that with this all started first, we know that there are a multitudeof health outcomes that differ in prevalence andseverity by race or ethnicity, or along other social demographic lines.

So we know that there aredifferences in these outcomes when it comes todifferent types of cancer, whether it's colorectalcancer, lung cancer, breast, ovarian cancer, whether it goes, whether we're talking about heart disease, or infants, maternal mortality, or even surgical outcomes, or vaginal birth after c-section, or in the likelihood ofsuccess and some of those, those sort of clinical scenarios.

And so that's not debated.

I think the real questionis, when we step back, and we see these, weobserve these differences in health outcomes by race specifically, the question is why.

And what you know, Dr.

Brody shared and what you just shared, Dr.

Harris, what we know is that thisis a complex, historical, multifaceted problem that spans multiple social ecological levels.

So it's a complex problemas to what is caused and led to these and promotedthese health (mumbles) that we have seen for a longtime and continue to see today.

Racial bias in health care, I think is a certainly an important contributorto this disparity.

Although right now we don'texactly know to what extent.

When we talk about racialbiases, in general, there are two ways that we think about it, and especially how theypresent healthcare.

So biases can be explicit, or implicit or subconscious.

So explicit biases, and I'mnot gonna spend too much time talking about this today.

But these are the typesof biases that directly or intentionally take intoaccount observations made based on an individual's race.

And so in recent weeks, there'sbeen a lot of discussion around whether we shouldreally be using race and some of these risk calculatorsor clinical algorithms.

And the reason for it beingcalled into question is if we don't know whythe disparities exists.

And then we go ahead and putand we do logistic regression, we put race as a predictive variable in a clinical algorithm, then we run the risk of perpetuating those disparities because it's not a genetic difference.

It's not, you know, race isnot, is a social construct.

It's not a biological, there'sno biological basis for race in this country.

So that's explicit bias.

The other type of bias, which I'd like to press a little bitmore into is implicit or subconscious bias.

And so these are theattitudes or stereotypes about an individual or a group of people that occur on thisunconscious involuntary level.

And the two important thingsto remember about implicit bias is that one, we all have it.

It's not a matter of, do youhave it or do you not have it? It's, we all have it.

And so it's not this, second point about it's not this intentional belief or idea.

And so the goal isn't whenwe talk about implicit bias, the goal is not to demonizeanyone or isolate anybody.

But nonetheless, we have tocommit to acknowledging them and addressing them if we are committing to the longitudinal work of anti-racism, specifically as it pertainsto this discussion.

And so with implicit bias, there have been studies that have shown that it can influence clinical decision making.

It can bias people, againon that subconscious or involuntary level, to make snap judgments that lead to decision thatmight disproportionately or differentially impactcertain groups of people, specifically black Americans.

And so, the thing aboutimplicit bias studies is that implicit biasitself is a difficult construct to study.

For good reason, right? It's difficult to measurebecause it's actually something that we, if we do anythingvoluntary with implicit bias, we voluntarily suppress it.

And so it's and then theway that we can measure it, at least in a in a study designis it tends to be through, the main mechanism tends to be through the Implicit AssociationTest with the IAT.

And so that is one way ofmeasuring implicit bias, it's not gonna capturethe entire spectrum of it.

And so, despite the studiesshowing some conflicting associations between implicitbias and health outcomes, one thing we do know conclusivelyis that a pro-white bias, a pro-male bias, a pro-straight bias exists among, in healthcareamong health professional that's been well established.

And so the question thenbecomes, what do we do about it? And as I was listeningto Dr.

Brody share about the idea that the factthat racism is trauma, racism is a pro inflammatory, it can add to that pro inflammatory state, it can add to that allostatic load.

I think what I'd liketo call attention to is, is understanding thatthis bias, racial bias, whether it's explicit orimplicit, is trauma itself.

And so if we can agree thattrauma in racism encounter outside the hospital, inthe community, in society is a traumatic experience thatcan add to allostatic load, then why should racial biasencountered in the hospital, in the health system beconsidered any differently? I think when we think about racism from a trauma perspective, there's an interesting association that we need to recognize.

The first one is that among people who have experienced substantial trauma, there is an association withthe sort of inconsistent or erratic use of healthcare, for example, We know that people who'veexperienced substantial trauma have an increased likelihood of scheduling more primary care appointments, but then no show to them or cancel them at the last minute.

There's also an associationwith between trauma in utilization of theemergency department, instead of having a regularprimary care provider, there's an association with higher out of pocket medical costs.

And so then racism itself has been shown to be associated withdelayed prenatal care.

And so I think theimportant part about bias that we have to realize isthat it's not just a driver of health disparities insome of these health outcomes that we pay attention to, butit actually can affect the way people who need health servicesengage in the health system.

And if they engage in a mannerthat is not exactly aligned with what the health systemwould like them to do or the way the health systemis set up for that kind of patient engagement, it can lead and promote, it can lead to promote, difficult patient encounters, fractured relationships, miscommunication, misunderstanding, which can obviously influence clinical decision making down the road.

– Dr.

Sonu, that issuch an important point.

I remember training, ofcourse here at Emory, we used to have a 75% no show rate.

And we used to just say oh, we expect a 75% no show rate.

And until we began to have conversations about why do we have a 75% no show rate.

Now we don't have the datathat all of you have mentioned.

We didn't have it backthen that we have now but that gets to some of the solutions and certainly we won'tbe able to get into all of those today but I veryimportant points you make.

We just have a few minutes left.

We are going to get around to everyone but I would want everyone to recognize that we justhave a few minutes left, but I do want to ask Dr.

McFadden, certainly right now with COVID-19.

And with the chronic and acuteinstances we see of racism.

And of course, some of theseacute instances are police brutality, talk briefly, in this very complex topic, and very complex times aboutthe intersection of COVID-19 and racism, and its impact on children and families in this moment.

– Sure, thank you.

So just trying to bringtogether what both doctors, Brody and Sonu have talked about.

We know that race is a social construct, and not a condition, but thedisparities that go along with race and racism are real.

And so what we see inthis time of COVID-19 is that the mostdisenfranchised communities African American communities, Latin-X communities, indigenous communities are athighest risk to contract COVID and to die from COVID.

When you look at someof the data from states across the nation, particularly in the southeast, where you see, for instance, in I think even in Illinois, 30% of, in Georgia 30% of the population is African American, but, you know, some 70% of the deaths have been African Americans.

And so this is a combination of some the disenfranchisement in communities.

You know, AfricanAmericans are more likely to be in those frontline essential jobs where there's limited PTO time, for children who we believeare less impacted by COVID.

Many of them are being caredfor by elderly caregivers, grandparents, relatives whoare high risk for COVID.

So we see this convergence really of these generations reallyof health disparities that put African Americansand communities of color at highest risk to be affected by COVID.

And so it's not surprisingthat we're seeing the sort of disparities thatwe're seeing at this point.

– And Dr.

Brody, you mentioned the key, and that's resilience.

Why don't some of the youth in your study or why didn't some ofthe youth in your study have the same level or reportsof adverse health outcomes? So I know we could talkabout that for hours and that that is, you know, one key issue as we think aboutinterventions or services, but can you briefly tell us what we know now about resiliency? – Sure.

About 20 years ago we wanted to find out, why was it that black childrenexposed to racist events over a long period of time, didn't have mental health consequences, such as increased depressive symptoms, anger, hostility, cynicism, and even aggression.

And what we found and whatinformed my answer here is that those children toldus that they had parents who in our language wereemotionally supportive.

Their parents were approachable.

They took their children'semotional temperature, that children would tell themabout racist experiences.

The parents helped them deal with this and process that experienceand gave them ideas and plans for how todeal with racist events in their schools andtheir larger communities.

In the study I talked aboutearlier, we found the same thing even though the study was done 15 years.

Those young high schoolpeople who were exposed to more racist events, but whodid not show any elevations in their biologicalmarkers that would forecast chronic disease also toldus that they had parents who they could talk to youabout this to help them process that experience with them.

They felt like they were in a partnership with their parents, theyhad an arena of comfort that protected them or acted as a shield from keeping those experiences from getting under their skin.

– Very good.

And I think a new frontier in our research is sort of looking at how systems can help with this because, you know, we talked about that weathering effects thosecumulative, not the acute, you know, racist eventsthat everyone can see, but those tiny everyday micro aggression.

So that is certainly anarea for future reference.

So last question, yes- – Dr.

Harris if I canmake one comment about what Dr.

Brody just said.

We know that safe, stable, nurturing environments, whether that's a parentor another caring adult, is critical to mitigatingadversity, whether it's racism, our you know, the other types of adversity that our children face.

So that's a crucial piece of, you know, what our society, what our healthcare systemcan do, to help with trauma for our young people fromracism or other forms of trauma.

– And speaking of trauma, Dr.

Sonu, talk a little bit abouttrauma-informed care.

I just believe that wereally need to increase our investment in trauma-informed care.

But if you could briefly let us know what a trauma-informed care is, and how can we bring atrauma-informed perspective really, inside of healthcare, but also in schools and other institutions? – Oh, yes, absolutely.

I think kind of going off withDr.

Brody just shared about what a powerful componentof resilience includes, which is that thatcentrality of relationships, and as Dr.

McFadden justshared, that every child needs those sort of safe, stable, nurturing relationships to thrive and to be resilientin the face of adversity.

Trauma-informed care isactually a framework that can it that is centered around that very idea of the healing power of unhealthyunnurturing relationship.

So I think of trauma-informedcare as not a checklist of things to do, but more of a framework, a lens by which we can beanchored to an empathetic or understanding or patient perspective.

And so, you know, Dr.

McFadden and I talked about this all the time, but thatthis big paradigm shift of what is trauma-informed care.

So it starts with A, weunderstand what trauma is, we understand what kind of health outcomes they're associated with.

And there's a multitudeof health outcomes.

And then we ask the question, well, if trauma is universal, but at the same time, it'sdisproportionately prevalence among vulnerable communities, historically marginalized and neglected populations, thenwhat should my guardrails be when I interact with not just my patients, but my colleagues, my staff, my family, my friends, right? And so the pivotal question, the paradigm shifting question is, it's not what's wrong with you, when you see behaviorin another person who that people would describe as problematic or counterproductive orcounterintuitive or self destructive that we stop the knee jerk impulse to say what's wrong with you.

But we pause we remember theassociation between trauma and health and thesenegative health outcomes.

And we ask instead, really what's happened.

And I think that mentalpivot helps us to get away from or making sure that we'renot just looking at people as a set of diseases orproblem list or they're defined by their medication, but really remembering that they're a person.

It's sort of a way for methat I honor the humanity of every patient that, infamily member that I work with, and so it's not an end all be all, but I think it's a startingplace as it pertains to the conversation around bias.

I think it's one safeguardthat we have to, you know, call that we're trained in.

Because right now this kindof training does not exist systematically in our health professional educational programs.

And so the idea that people in healthcare, health professionals canmake it all the way through their training, and not understandand learn about this link between trauma and healthand the ways that it shows up in so many different chronic diseases and disease and disabilityand early death, to me is a problem thatwe have to actively partner together to address.

– And I really like the wayyou put that and perhaps I am big on saying words matter.

So I wonder, which will be aconversation for another day, but I wonder if we should not talk about trauma-informed carebecause then people get into care, but rather atrauma-informed framework for all services, institutions, and care that we give, so it's certainly that's a great conversation that weshould have going forward.

Well, again, let me thank my panelists.

I could have talked toyou all, all day today.

These are such important topics and they couldn't be more important for a point of discussion at this time.

We heard today about theimportance of appreciating and understanding adversechildhood experiences in general as we know them already.

But also we need toinclude racism as a trauma for children and adults.

We also learned aboutthe importance of having a trauma-informed framework really, for all of the services and institutions that touch people, again, certainly in healthcare, but also in our educational systems and in our justice systems.

And we learned about resiliency.

We certainly know that racismdoes impact health outcomes both in the short-term and the long-term.

But we also learned today that resiliency and learning about resiliencyand children having a safe, stable, nurturing environment can add and support resilience inchildren and in adults.

So thank you very muchfor joining us today.

I hope you've had the opportunityto learn something new.

I did.

But more importantly, I hopetoday's discussion is a call to action for all of us, not only to learn more, but to do more.

So if you'd like further information, you can see resources on the screen.

Certainly, you can visit thewebsite of Resilient Georgia.

You can learn more about the Center for FamilyResources Prevention Program at their website.

And if you or anyone inyour family needs access to mental health services, you can call the GeorgiaCrisis and Access Line, that's GCAL at 1-800-715-4225.

You can get immediate accessto routine or crisis services.

Or you can use the appMyGCAL to text or chat.

Thank you.

.

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Mental Fitness For Resilience Campaign – The Trauma of Racism

– Welcome.

I'm Dr.

Patrice Harris.

I'm a pediatric psychiatristhere in Atlanta.

I completed my Residencyand Fellowship training in child and adolescentand forensic psychiatry at the Emory UniversitySchool of Medicine.

I just completed my termas the 174th president of the American Medical Association, and I'm the first African American woman to hold that office.

I am certainly honored tomoderate this panel today as part of the partnership between GPB and Resilient Georgia and this is part of the Mental Fitnessfor Resilience Campaign.

Today's panel will focus on health equity, racism and resiliency.

And I am so honored to be joined by three distinguished panelists.

Dr.

Terri McFadden isa general pediatrician and professor in theDepartment of Pediatrics at the Emory UniversitySchool of Medicine, she is also director ofPrimary Care Initiatives with partners for Equity inChild and Adolescent Health.

She is currently the presidentof the Georgia Chapter of the American Academy of Pediatrics.

Her academic and professional interests include health equity, comprehensive care for the underserved, childhood injury prevention, brain development and medical education.

Dr.

Gene Brody is Regents professor and director of theCenter For Family Research at the University of Georgia.

The Center For FamilyResearch has been named a center of excellence by the National Institute on Drug Abuse.

And then the last two yearswas given the advances in Culture And DiversityIn Prevention Science Award by the Society For Prevention, Research and the President's Award of distinction for innovative team science from the Georgia Clinical andTranslational Science Alliance.

And last but certainly notleast, is Dr.

Stan Sonu.

Dr.

Sonu is an assistantprofessor of internal medicine and pediatrics at the EmoryUniversity School of Medicine.

Again, hope you noticethe Emory thing today.

And he also serves as anAssociate Program Director for the Emory InternalMedicine Residency Program.

Dr.

Sonu obtained his medical degree at the Medical College of Georgia, completed his residency incombined internal medicine and pediatrics at Rush UniversityMedical Center in Chicago, and did a fellowship at the Cook County, Preventive Medicine andPublic Health Program, during which he also obtained his MPH degree at Northwestern.

His research interests include addressing and preventing adversechildhood experiences and integration of trauma-informed care and clinical practice.

And I forgot to mentionthat Dr.

Gene Brody also has an appointment at the Emory University RollinsSchool of Public Health.

So Dr.

McFadden, let me start with you.

Talk a little bit about racism and how racism can be or is not.

I'll wait to hear your opinion and Adverse Childhood Experience or ACE, we hear a lot of talk about that, how that relates to toxic stress? – Thank you, Dr.

Harrisand fellow panelists.

It's a pleasure to be here this morning.

So we know that racism is acore determinant of health and leads to lots of social inequities, but independent of the social inequities, racism can be an adversechildhood experience.

And, you know, as myfellow panelists know, there's been a lot of talk about ACEs or Adverse Childhood Experiences as the adversity, the scienceof adversity has developed.

And just to give a quick a capsule view of adverse childhood experiences, the science tells us that traumatic events that children experience early in life not only affects theirpsyche or their psychology while they're young, but itreally can predict long-term physical and mental healthconsequences for those children as they progress into adulthood.

So it's not just a pediatric issue.

It's an issue around thewhole life trajectory.

And so the way that we believe that these adverse childhoodexperiences manifest is because of toxic stress.

Now, there's a lot of work(indistinct) about trauma and stress and it's hardsometimes to separate out, you know, all the thingsthat we're talking about.

But stress in and of itself isnot necessarily a bad thing.

The center for thedeveloping child has come up with a framework around stress, where they talk about positive stress, tolerable stress and toxic stress.

So positive stress is when a child falls and a loving adult picksthem up, dust them off, and they find out that yes, they can cope, they can deal with it.

Tolerable stress may bea little less normative.

These are not normal experiences.

It may be significant, like the death of a parent, or a natural disaster, but again with a loving adult, a safe, stable, nurturing environment that child recovers, develops resilience and understand coping mechanisms.

And so it can be valuable to them.

They learned that they canget through a bad situation, but with toxic stress theexposure to trauma is unrelenting and severe, and there's acouple that with there not being a loving adult, a safe, stable, nurturing environment to mitigate that stress, that child experiences an elevation of theirfight or flight hormones, which can affect brain development, particularly in the partsof the brain that have to do with executive function, which is a way that we learn, but it also affects the immune response and the immune system.

And even more, I thinkconcerning is the genetics, what we described as epigenetics, the way that genes unfold.

So this can not only affect the child in their early childhood, in their brain development, but their lifelong trajectory of health, as well as it can be intergenerational, not just from the social inequities, but from actual changes to the genome.

So this is a significantissue for children and racism clearly is one of those ACEs, even though it wasn't included in that seminal study that looked at 10 exposures that children can have, if you look at more of a community experience, weknow that racism is clearly one of those communityexperiences that can impact a child's brain developmentand long-term health.

– Great, thank you.

And Dr.

Brody, pick upon that a little bit and talk about racism and howit can affect again, life, long health, particularlyaround chronic diseases.

– Sure.

It's great to be here this morning.

And Dr.

Harris, thankyou for all you've done to promote the health andwell being of all Americans.

– [Patrice] Thank you.

– Our work focuses onchildren and families in the southeastern United States.

Those states that beginwith North Carolina, South Carolina, Georgia, Mississippi and Alabama, and if we look closely at theepidemiology of what it's like to raise a child andgrow up in those places, it can be very challenging, particularly if you're a black person.

The poverty rates are amongthe highest in the nation for black children and families, and over half or nearly 60% of black children in theseplaces grow up in poverty.

And what's remarkable is thatdespite this epidemiology, so many black children growup to be competent, healthy, and have good mental health.

If we look though, at the epidemiology, or the prevalence ofchronic disease at midlife, we find that children whogrow up in these places are 30% more likely tohave chronic disease, by chronic diseases, I mean, heart disease, diabetes, hypertension, stroke, and even dementia.

And the prevailing view has been that these diseases appear at midlife.

And actually, we take adifferent point of view on that.

We look at and believe that the origins of these chronic diseasesbegin in childhood, early childhood, andmaybe even before birth.

An important contributorto the development of chronic disease is webelieve that across childhood, children are exposed to racist encounters, and those racist encounterscan change their biology in a way that makes it morelikely that they'll develop chronic disease whenthey do reach midlife.

And this is important froma prevention point of view because if we canintervene during childhood and develop shieldsfrom racist encounters, we can promote the health ofchildren, and their children.

So we set about tofigure out if encounters during adolescence somehowchanges children's biology, adolescence biology, sothat they become more likely to develop a chronic disease at midlife.

And this was no easy feat, and we started about 10 years ago.

And what we did is we trackedexposure to racist events in several hundred ofblack high school students, and we follow them forthree or four years.

And then after they left high school, we collected a bundle ofmarkers of their health, including their stress hormones, cortisol, epinephrine, or norepinephrine.

We looked at the levels ofcirculating inflammation in their bodies, we lookedat their blood pressure, we looked at their (indistinct).

And we wanted to see ifexposure to racist encounters would be associated withthis bundle of health markers that together predict or wouldpredict the chronic diseases of aging later on in life.

And what we found wasindeed, more exposure to racist encounters whichcould be slurs or physical harm, false accusations from the police or for business owners orhaving a guidance counselor telling you that you're not smart enough to take a certain course orto go to a certain college.

All of those things overtime together, predicted those markers that wouldindicate at midlife that these young people would indeed experience chronic disease.

An important thing we found, though, was that there was asizable minority of youth who were exposed tothese racist encounters and yet did not show elevationin these health markers that would forecast for health later on.

And this is a very importantroom to understand.

– You know that that is critical.

I get that question alot about resiliency, particularly now with COVID-19 and people ask if Ipredict a mental crisis.

And certainly it's no way toknow if there will be a crisis, however, we define that crisis.

So it's not inevitable, though, but we need to get whatwe need to do right now.

And one more point and thenthis leads to Dr.

Sonu, is I'm so glad that youtalked about poverty.

And certainly, that's oneof those social determinants of health that, again, has been driven by larger structuraldeterminants of health, such as racism and biasand all of those things.

But you also separated outracism as its own independent variables, because I think weknow just across the spectrum, we certainly don't havetime to go into it today.

But no matter your economic security, you can still be affectedand impacted by racism.

And I think that's one ofthe reasons we are thinking that even African Americanwomen who have insurance and have some economicsecurity are still are impacted by the statistics aroundmaternal mortality.

So I'm so glad that you'relooking at these independent variables, because fartoo often people think that there has to bean intersection there.

And so, Dr.

Sonu, you'vedone a lot of work again, speaking of racism and biases, and how these show up in healthcare.

So say a little bit moreabout what you can teach us about these biases in healthcare.

– Well, thank you so much, Dr.

Harris.

It's an honor to be here andto be a part of this panel.

Thank you for that question.

I think what I'll start withis to just make the point that with this all started first, we know that there are a multitudeof health outcomes that differ in prevalence andseverity by race or ethnicity, or along other social demographic lines.

So we know that there aredifferences in these outcomes when it comes todifferent types of cancer, whether it's colorectalcancer, lung cancer, breast, ovarian cancer, whether it goes, whether we're talking about heart disease, or infants, maternal mortality, or even surgical outcomes, or vaginal birth after c-section, or in the likelihood ofsuccess and some of those, those sort of clinical scenarios.

And so that's not debated.

I think the real questionis, when we step back, and we see these, weobserve these differences in health outcomes by race specifically, the question is why.

And what you know, Dr.

Brody shared and what you just shared, Dr.

Harris, what we know is that thisis a complex, historical, multifaceted problem that spans multiple social ecological levels.

So it's a complex problemas to what is caused and led to these and promotedthese health (mumbles) that we have seen for a longtime and continue to see today.

Racial bias in health care, I think is a certainly an important contributorto this disparity.

Although right now we don'texactly know to what extent.

When we talk about racialbiases, in general, there are two ways that we think about it, and especially how theypresent healthcare.

So biases can be explicit, or implicit or subconscious.

So explicit biases, and I'mnot gonna spend too much time talking about this today.

But these are the typesof biases that directly or intentionally take intoaccount observations made based on an individual's race.

And so in recent weeks, there'sbeen a lot of discussion around whether we shouldreally be using race and some of these risk calculatorsor clinical algorithms.

And the reason for it beingcalled into question is if we don't know whythe disparities exists.

And then we go ahead and putand we do logistic regression, we put race as a predictive variable in a clinical algorithm, then we run the risk of perpetuating those disparities because it's not a genetic difference.

It's not, you know, race isnot, is a social construct.

It's not a biological, there'sno biological basis for race in this country.

So that's explicit bias.

The other type of bias, which I'd like to press a little bitmore into is implicit or subconscious bias.

And so these are theattitudes or stereotypes about an individual or a group of people that occur on thisunconscious involuntary level.

And the two important thingsto remember about implicit bias is that one, we all have it.

It's not a matter of, do youhave it or do you not have it? It's, we all have it.

And so it's not this, second point about it's not this intentional belief or idea.

And so the goal isn't whenwe talk about implicit bias, the goal is not to demonizeanyone or isolate anybody.

But nonetheless, we have tocommit to acknowledging them and addressing them if we are committing to the longitudinal work of anti-racism, specifically as it pertainsto this discussion.

And so with implicit bias, there have been studies that have shown that it can influence clinical decision making.

It can bias people, againon that subconscious or involuntary level, to make snap judgments that lead to decision thatmight disproportionately or differentially impactcertain groups of people, specifically black Americans.

And so, the thing aboutimplicit bias studies is that implicit biasitself is a difficult construct to study.

For good reason, right? It's difficult to measurebecause it's actually something that we, if we do anythingvoluntary with implicit bias, we voluntarily suppress it.

And so it's and then theway that we can measure it, at least in a in a study designis it tends to be through, the main mechanism tends to be through the Implicit AssociationTest with the IAT.

And so that is one way ofmeasuring implicit bias, it's not gonna capturethe entire spectrum of it.

And so, despite the studiesshowing some conflicting associations between implicitbias and health outcomes, one thing we do know conclusivelyis that a pro-white bias, a pro-male bias, a pro-straight bias exists among, in healthcareamong health professional that's been well established.

And so the question thenbecomes, what do we do about it? And as I was listeningto Dr.

Brody share about the idea that the factthat racism is trauma, racism is a pro inflammatory, it can add to that pro inflammatory state, it can add to that allostatic load.

I think what I'd liketo call attention to is, is understanding thatthis bias, racial bias, whether it's explicit orimplicit, is trauma itself.

And so if we can agree thattrauma in racism encounter outside the hospital, inthe community, in society is a traumatic experience thatcan add to allostatic load, then why should racial biasencountered in the hospital, in the health system beconsidered any differently? I think when we think about racism from a trauma perspective, there's an interesting association that we need to recognize.

The first one is that among people who have experienced substantial trauma, there is an association withthe sort of inconsistent or erratic use of healthcare, for example, We know that people who'veexperienced substantial trauma have an increased likelihood of scheduling more primary care appointments, but then no show to them or cancel them at the last minute.

There's also an associationwith between trauma in utilization of theemergency department, instead of having a regularprimary care provider, there's an association with higher out of pocket medical costs.

And so then racism itself has been shown to be associated withdelayed prenatal care.

And so I think theimportant part about bias that we have to realize isthat it's not just a driver of health disparities insome of these health outcomes that we pay attention to, butit actually can affect the way people who need health servicesengage in the health system.

And if they engage in a mannerthat is not exactly aligned with what the health systemwould like them to do or the way the health systemis set up for that kind of patient engagement, it can lead and promote, it can lead to promote, difficult patient encounters, fractured relationships, miscommunication, misunderstanding, which can obviously influence clinical decision making down the road.

– Dr.

Sonu, that issuch an important point.

I remember training, ofcourse here at Emory, we used to have a 75% no show rate.

And we used to just say oh, we expect a 75% no show rate.

And until we began to have conversations about why do we have a 75% no show rate.

Now we don't have the datathat all of you have mentioned.

We didn't have it backthen that we have now but that gets to some of the solutions and certainly we won'tbe able to get into all of those today but I veryimportant points you make.

We just have a few minutes left.

We are going to get around to everyone but I would want everyone to recognize that we justhave a few minutes left, but I do want to ask Dr.

McFadden, certainly right now with COVID-19.

And with the chronic and acuteinstances we see of racism.

And of course, some of theseacute instances are police brutality, talk briefly, in this very complex topic, and very complex times aboutthe intersection of COVID-19 and racism, and its impact on children and families in this moment.

– Sure, thank you.

So just trying to bringtogether what both doctors, Brody and Sonu have talked about.

We know that race is a social construct, and not a condition, but thedisparities that go along with race and racism are real.

And so what we see inthis time of COVID-19 is that the mostdisenfranchised communities African American communities, Latin-X communities, indigenous communities are athighest risk to contract COVID and to die from COVID.

When you look at someof the data from states across the nation, particularly in the southeast, where you see, for instance, in I think even in Illinois, 30% of, in Georgia 30% of the population is African American, but, you know, some 70% of the deaths have been African Americans.

And so this is a combination of some the disenfranchisement in communities.

You know, AfricanAmericans are more likely to be in those frontline essential jobs where there's limited PTO time, for children who we believeare less impacted by COVID.

Many of them are being caredfor by elderly caregivers, grandparents, relatives whoare high risk for COVID.

So we see this convergence really of these generations reallyof health disparities that put African Americansand communities of color at highest risk to be affected by COVID.

And so it's not surprisingthat we're seeing the sort of disparities thatwe're seeing at this point.

– And Dr.

Brody, you mentioned the key, and that's resilience.

Why don't some of the youth in your study or why didn't some ofthe youth in your study have the same level or reportsof adverse health outcomes? So I know we could talkabout that for hours and that that is, you know, one key issue as we think aboutinterventions or services, but can you briefly tell us what we know now about resiliency? – Sure.

About 20 years ago we wanted to find out, why was it that black childrenexposed to racist events over a long period of time, didn't have mental health consequences, such as increased depressive symptoms, anger, hostility, cynicism, and even aggression.

And what we found and whatinformed my answer here is that those children toldus that they had parents who in our language wereemotionally supportive.

Their parents were approachable.

They took their children'semotional temperature, that children would tell themabout racist experiences.

The parents helped them deal with this and process that experienceand gave them ideas and plans for how todeal with racist events in their schools andtheir larger communities.

In the study I talked aboutearlier, we found the same thing even though the study was done 15 years.

Those young high schoolpeople who were exposed to more racist events, but whodid not show any elevations in their biologicalmarkers that would forecast chronic disease also toldus that they had parents who they could talk to youabout this to help them process that experience with them.

They felt like they were in a partnership with their parents, theyhad an arena of comfort that protected them or acted as a shield from keeping those experiences from getting under their skin.

– Very good.

And I think a new frontier in our research is sort of looking at how systems can help with this because, you know, we talked about that weathering effects thosecumulative, not the acute, you know, racist eventsthat everyone can see, but those tiny everyday micro aggression.

So that is certainly anarea for future reference.

So last question, yes- – Dr.

Harris if I canmake one comment about what Dr.

Brody just said.

We know that safe, stable, nurturing environments, whether that's a parentor another caring adult, is critical to mitigatingadversity, whether it's racism, our you know, the other types of adversity that our children face.

So that's a crucial piece of, you know, what our society, what our healthcare systemcan do, to help with trauma for our young people fromracism or other forms of trauma.

– And speaking of trauma, Dr.

Sonu, talk a little bit abouttrauma-informed care.

I just believe that wereally need to increase our investment in trauma-informed care.

But if you could briefly let us know what a trauma-informed care is, and how can we bring atrauma-informed perspective really, inside of healthcare, but also in schools and other institutions? – Oh, yes, absolutely.

I think kind of going off withDr.

Brody just shared about what a powerful componentof resilience includes, which is that thatcentrality of relationships, and as Dr.

McFadden justshared, that every child needs those sort of safe, stable, nurturing relationships to thrive and to be resilientin the face of adversity.

Trauma-informed care isactually a framework that can it that is centered around that very idea of the healing power of unhealthyunnurturing relationship.

So I think of trauma-informedcare as not a checklist of things to do, but more of a framework, a lens by which we can beanchored to an empathetic or understanding or patient perspective.

And so, you know, Dr.

McFadden and I talked about this all the time, but thatthis big paradigm shift of what is trauma-informed care.

So it starts with A, weunderstand what trauma is, we understand what kind of health outcomes they're associated with.

And there's a multitudeof health outcomes.

And then we ask the question, well, if trauma is universal, but at the same time, it'sdisproportionately prevalence among vulnerable communities, historically marginalized and neglected populations, thenwhat should my guardrails be when I interact with not just my patients, but my colleagues, my staff, my family, my friends, right? And so the pivotal question, the paradigm shifting question is, it's not what's wrong with you, when you see behaviorin another person who that people would describe as problematic or counterproductive orcounterintuitive or self destructive that we stop the knee jerk impulse to say what's wrong with you.

But we pause we remember theassociation between trauma and health and thesenegative health outcomes.

And we ask instead, really what's happened.

And I think that mentalpivot helps us to get away from or making sure that we'renot just looking at people as a set of diseases orproblem list or they're defined by their medication, but really remembering that they're a person.

It's sort of a way for methat I honor the humanity of every patient that, infamily member that I work with, and so it's not an end all be all, but I think it's a startingplace as it pertains to the conversation around bias.

I think it's one safeguardthat we have to, you know, call that we're trained in.

Because right now this kindof training does not exist systematically in our health professional educational programs.

And so the idea that people in healthcare, health professionals canmake it all the way through their training, and not understandand learn about this link between trauma and healthand the ways that it shows up in so many different chronic diseases and disease and disabilityand early death, to me is a problem thatwe have to actively partner together to address.

– And I really like the wayyou put that and perhaps I am big on saying words matter.

So I wonder, which will be aconversation for another day, but I wonder if we should not talk about trauma-informed carebecause then people get into care, but rather atrauma-informed framework for all services, institutions, and care that we give, so it's certainly that's a great conversation that weshould have going forward.

Well, again, let me thank my panelists.

I could have talked toyou all, all day today.

These are such important topics and they couldn't be more important for a point of discussion at this time.

We heard today about theimportance of appreciating and understanding adversechildhood experiences in general as we know them already.

But also we need toinclude racism as a trauma for children and adults.

We also learned aboutthe importance of having a trauma-informed framework really, for all of the services and institutions that touch people, again, certainly in healthcare, but also in our educational systems and in our justice systems.

And we learned about resiliency.

We certainly know that racismdoes impact health outcomes both in the short-term and the long-term.

But we also learned today that resiliency and learning about resiliencyand children having a safe, stable, nurturing environment can add and support resilience inchildren and in adults.

So thank you very muchfor joining us today.

I hope you've had the opportunityto learn something new.

I did.

But more importantly, I hopetoday's discussion is a call to action for all of us, not only to learn more, but to do more.

So if you'd like further information, you can see resources on the screen.

Certainly, you can visit thewebsite of Resilient Georgia.

You can learn more about the Center for FamilyResources Prevention Program at their website.

And if you or anyone inyour family needs access to mental health services, you can call the GeorgiaCrisis and Access Line, that's GCAL at 1-800-715-4225.

You can get immediate accessto routine or crisis services.

Or you can use the appMyGCAL to text or chat.

Thank you.

.

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