Structural Trauma and Toxic Stress

Lifecourse Roots of Health Inequities

Toms J. Aragn, MD, DrPH

CCLHO/HOAC Semi-annual Meeting, Bakersfield, CA, May 4, 2017
Health Officer, City & County of San Francisco
Director, Population Health Division (PHD)
San Francisco Department of Public Health
http://www.tomas.pro (my home page)

PDF slides produced in Rmarkdown LATEX BeamerMetropolis theme

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1 Background and introduction

2 Trauma-informed approach in S.F.

3 San Francisco Public health examples

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1 Background and introduction

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Special acknowledgments (in alphabetical order)

Ayanna Bennett, Lead, Black/African American Health Initiative

Barbara A. Garcia, Director of Health, SFDPH LEAD Initiative
Jacque McCright, SFHN Hypertension Equity Workgroup, PHD representative
Ellen Chen, Lead, SFHN Hypertension Equity Workgroup
Emily Weinstein, Trauma-Informed Community Building
Jessica Wolin, Trauma-Informed Community Building
Kenneth Epstein, DPH Trauma-informed Systems Initiative
Kenneth Hardy, Racial Humility consultant/trainer
Lakisha Garduo, SFHN Hypertension Equity Workgroup
Rhonda Simmons, Division of Diversity, Inclusion and Workforce Development, HR
Richa Dhanju, Division of Diversity, Inclusion and Workforce Development, HR
Rita Nguyen, SFHN Hypertension Equity Workgroup, PHD representative
Sarah Cox, SFHN Hypertension Equity Workgroup
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Some definitions

Health is a state of complete physical, mental and social well-being and not merely the
absence of disease or infirmity (World Health Organization, 1946).
Public health is what we, as a society, do collectively to assure the conditions in which
people can be healthy (Institute of Medicine, 1988).
Population health1 is a systems2 framework for studying and improving the health of
populations through collective action and learning (Aragon & Garcia, 2017).3

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Essential population health goals include (1) protecting and promoting health and equity, (2)
transforming people and place, (3) ensuring a healthy planet, and (4) achieving health equity.
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Complex adaptive socioecological systems (CASES)
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For discussion of the term "population health" see http://www.phdata.science/p/about.html
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More definitions4

Health disparities are differences that exist among specific population groups in the
United States in the attainment of full health potential that can be measured by
differences in incidence, prevalence, mortality, burden of disease, and other adverse
health conditions.
Health equity is the state in which everyone has the opportunity to attain full health
potential and no one is disadvantaged from achieving this potential because of social
position or any other socially defined circumstance.

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National Academies of Sciences, Engineering, and Medicine. 2017. Communities in action: Pathways
to health equity. Washington, DC: The National Academies Press. doi: 10.17226/24624.
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Health inequity arises from root causes in two clusters:5

1. Intrapersonal, interpersonal, institutional, and systemic mechanisms (also referred

to as structural inequities) that organize the distribution of power and resources
differentially across lines of race, gender, class, sexual orientation, gender
expression, and other dimensions of individual and group identity.
2. The unequal allocation of power and resourcesincluding goods, services, and
societal attentionwhich manifests itself in unequal social, economic, and
environmental conditions, also called the determinants of health.

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National Academies of Sciences, Engineering, and Medicine. 2017. Communities in action: Pathways
to health equity. Washington, DC: The National Academies Press. doi: 10.17226/24624.
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Population health socioecological framework6

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Source: California Department of Public Health, Office of Health Equity
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Causes of premature deaths in men and women, San Francisco, 20032004

Age-adjusted Expected Years of Life Lost (eYLL): Male (left), Female (right); Black (colored red), 4
Latino, Asian/PI, + White; Source: Aragn TJ, et al. PubMed ID: 18402698 9
The lifecourse, two-generation roots of health and well-being, 20042016

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Structural trauma and toxic stressThe roots of racial health inequities
Foundational themes

Communities suffer from the effects of chronic trauma/stress

Life-course of toxic stress, structural racism, and discrimination
Toxic stress effects a childs learning, behavior, and health for life
Policy, systems, structural priorities must reach the most vulnerable
Neighborhood, Family-centered, Life-course (NFL)7 focus is essential
Trauma effects are transmitted across generations socially and biologically
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The acronym NFL makes us think of the National Football League who is infamous for the
systematic denial of permanent brain injury (chronic trauma encephalopathy [CTE]) from playing
football (see http://www.pbs.org/wgbh/frontline/film/league-of-denial/). For us, NFL means having a
relentless focus on the Neighborhood, Family-centered, Life-course (NFL) approach when we prioritize
social policy: we aim to always reach the most vulnerablechildren ages 0 to 5 years.
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Childhood adversities and mental health outcomes in homeless adults
San Francisco, 2016 (Am J Geriatr Psychiatry 2016)

Source: http://www.centerforyouthwellness.org/
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How our core capabilities work (1/2)
Executive function, attention, and automatic and intentional self-regulation

Executive function skill proficiency

Source: Center on the Developing Child (http://developingchild.harvard.edu/)

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How our core capabilities work (2/2)
Executive function, attention, and automatic and intentional self-regulation

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2 Trauma-informed approach in S.F.

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Designing a healing and learning organization, transforming people and place
Lead: Barbara Garcia, and inspired by the Kresge Emerging Leaders in Public Health

Adapted from the Lean Transformation Framework (http://www.lean.org)

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Core principles of trauma-informed systems
SFDPH initiative led by Dr. Kenneth Epstein

We serve diverse, traumatized communities under chronic, toxic stress. Our diverse staff
often live in or come from these communities. Therefore, we need to design healing
organizations. Here are six core principles of healing, trauma-informed systems:

1. Understanding trauma and stress

2. Compassion and dependability
3. Safety and stability
4. Collaboration and empowerment
5. Cultural humility and responsiveness
6. Resilience and recovery
For more information visit http://www.t2bayarea.org.

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Cultural/Racial Humility

In 1998, Melanie Tervalon and Jann Murray-Garca published a groundbreaking article

that challenged the concept of cultural competency with the concept of cultural
humility. Cultural humility8 is committing to lifelong learning, critical self-reflection,
and personal and institutional transformation.

1. Commit to lifelong learning and critical self-reflection.

2. Realize our own power, privilege, and prejudices.
3. Redress power imbalances for respectful partnerships.
4. Promote institutional accountability.

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Adapted from Drs. Melanie Tervalon, Jann Murray-Garca, and Kenneth Hardy
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3 San Francisco Public health
examples

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Black/African American Health Initiative (BAAHI), April, 2014
Lead: Ayanna Bennett, San Francisco Department of Public Health

BAAHI components
1. Collective impact
2. Workforce development
3. Cultural humility training
Collective impact
1. Heart health (focus: hypertension)
2. Behavioral health (focus: alcohol)
3. Womens Health (focus: breast cancer)
4. Sexual Health (focus: Chlamydia)

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SF Health Network Primary Care Hypertension Equity Workgroup
Leads: Ellen Chen, Lakisha Garduo, and Sarah Cox (1/4)Lean performance improvement

Equity is a True North metric for

all SFDPH Lean programs.

Lean thinking and practicea is

systematically developing people to
solve problems and consuming the
fewest possible resources while
continuously improving processes
to provide value to community
members and prosperity to society.
a
http://www.lean.org

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SF Health Network Primary Care Hypertension Equity Workgroup
Lead: Ellen Chen, Lakisha Garduo, and Sarah Cox (2/4)Headline Performance Indicator

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SF Health Network Primary Care Hypertension Equity Workgroup
Leads: Ellen Chen, Lakisha Garduo, and Sarah Cox (3/4)Performance Indicators, by Clinic

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SF Health Network Primary Care Hypertension Equity Workgroup
Leads: Ellen Chen, Lakisha Garduo, and Sarah Cox (4/4)Monthly True North messaging

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Healthy Hearts San Francisco (HHSF)CDC REACH Grant
Leads: Jacque McCright, Kathleen Edmunds, Giuliana Martinez, Wanda Anderson

HHSF Focus Areas

1. Targeting lowest-income African
American and Latino census tracts
2. Mobilizing free physical activity
resources in the community
3. Primary care green prescriptions for
physical activity
4. Community navigators in the clinics

Web site: http://healthyhearts.org

YouTube: https://youtu.be/aZIjTSfc2lk

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Healthy Hearts San Francisco (HHSF)CDC REACH Grant
Leads: Jacque McCright, Kathleen Edmunds, Giuliana Martinez, Wanda Anderson

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Trauma-informed community building (San Francisco)
Leads: Emily Weinstein, Bridge Housing and Jessica Wolin, San Francisco State University

TRAUMA INFORMED
COMMUNITY BUILDING
A Model for Strengthening Community in
Trauma Affected Neighborhoods

Weinstein, Wolin, Rose

Source: http://bridgehousing.com/PDFs/TICB.Paper5.14.pdf
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The Leading Population Health FrameworkOverall concepts
Transforming self, teams, organizations, and communities

Source: http://www.phlean.org 28
The Leading Population Health FrameworkPutting it all together!

Leadership is getter results in a

way that inspires trust.
. . . Stephen M.R. Covey

Population health goals:

1. Protecting and promoting
health and equity
2. Transforming people and place;
3. Ensuring a healthy planet; and
4. Achieving health equity.

Source: http://www.phlean.org

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Questions? Preguntas? Mga katanungan? Des questions?
Acknowledgments (in alphabetical order)

Abbie Yant, Alice Chen, Amor Santiago, Anda Kuo, Aneeka Chaudhry, Ayanna Bennett, Barbara
A Garcia, Barry Lawlor, Belle Taylor-McGhee, Brittney Doyle, Cecilia Thomas, Christine Siador,
Cindy Garcia, Colleen Chawla, Colleen Matthews, Curtis Chan, Darlene Daevu, David Serrano
Sewell, Deborah Sherwood, Deena Lahn, Dianne M. Easton, Ellen Chen, Estela Garcia, Greg
Wagner, Guliana Martinez, Hali Hammer, Iman Nazeeri-Simmons, Isela Ford, Israel
Nieves-Rivera, Jacque McCright, James Illig, Jeannie Balido, Jenee Johnson, Jessica Wolin, John
Grimes, Jonathan Butler, Jonathan Fuchs, Judith Martin, Karen Pierce, Karen Strickland,
Kavoos Ghane Bassiri, Kenneth Epstein, Kenneth Hardy, Kevin Grumbach, Kim Shine, Kirsten
Bibbins-Domingo, Leigh Kimberg, Lisa Golden, Maria X Martinez, Marlo Simmons, Mary Hansell,
Maximilian Rocha, Michelle A. Albert, Michelle Kirian, Michelle Long, Muntu Davis, Nadine
Burke Harris, Neal Halfon, Patricia Erwin, Paula Fleisher, Paula Jones, Perry Lang, Rachael
Kagan, Rhea Bailey, Rhonda Simmons, Roberto Vargas, Robin George, Roland Pickens, Ron
Weigelt, Stuart Fong, Susan Ehrlich, Susan Philip, Tessa Rouverol Collejo, Thomas Boyce,
Tracey Packer, Veronica Shepard, Wanda Materre, Wanetta Davis, Wilma Wooten, Wylie Liu 30
Key online resources

BARHII Bay Area Regional Health Inequities Initiative

http://barhii.org/
Government Alliance on Race and Equity
http://www.racialequityalliance.org/
Center for Social Inclusion
http://www.centerforsocialinclusion.org/
Center on the Developing Child
http://developingchild.harvard.edu/
The Raising of America
http://www.raisingofamerica.org/
Population Health Lean (TJA)
http://www.phlean.org/

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