Structural Trauma and Toxic Stress!Inter-generational Roots of Adult Health Inequities

Tomas J. Aragon, MD, DrPH

Health Officer, City & County of San FranciscoDirector, Population Health Division

San Francisco Department of Public HealthFaculty, UC Berkeley School of Public Health

Member, Big Cities Health CoalitionURL: http://populationhealth.science

NACCHO Annual Conference, July, 2016

Tomas J. Aragon, MD, DrPH (SFDPH) Roots of Adult Health Inequities NACCHO, July, 2016 1 / 16

Overview

Foundational themes

1 Life-course of structural racism, discrimination, and chronic stress

2 Individual and communities suffer from the effects of trauma

3 The effects of trauma are transmitted across generations

4 Toxic stress effects child brain, body, and behavior for life

Trauma-Informed Approaches in San Francisco

1 Trauma-informed systems training (Bay Area)

2 Trauma-Informed Community Building (TICB)

3 Black/African American Health Initiative (BAAHI)

4 Healthy Hearts San Francisco (CDC REACH grant)

5 Our Children, Our Families (collective impact)

6 San Francisco Health Improvement Partnership (sfhip.org)

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Causes of Premature Deaths in Men & WomenSan Francisco, 2003–2004 (How do we explain racial health inequities and resilience?)

Age-adjusted Expected Years of Life Lost (eYLL): Male (left), Female (right); © Black (coloredred), 4 Latino, × Asian/PI, + White; Source: Aragon TJ, et al. PubMed ID: 18402698

Tomas J. Aragon, MD, DrPH (SFDPH) Roots of Adult Health Inequities NACCHO, July, 2016 3 / 16

A Framework for Health EquityAlameda County Public Health Department—Adapted from BARHII.org

Tomas J. Aragon, MD, DrPH (SFDPH) Roots of Adult Health Inequities NACCHO, July, 2016 4 / 16

Adverse Childhood Experiences and Adult Heart Disease

Source: http://www.developingchild.harvard.edu

Tomas J. Aragon, MD, DrPH (SFDPH) Roots of Adult Health Inequities NACCHO, July, 2016 5 / 16

Lifecourse Health Development—Variable trajectories

Source: Halfon N, Larson K, Lu M, Tullis E, Russ S. Lifecourse health development: past,present and future. Matern Child Health J. 2014;18(2):344-65. PubMed PMID: 23975451;

Tomas J. Aragon, MD, DrPH (SFDPH) Roots of Adult Health Inequities NACCHO, July, 2016 6 / 16

The Lifecourse Health Development of Adult InequitiesReconceptualizing Early Lifecourse Policies and Programs to Strengthen Lifelong Health

Source: Center for the Developing Child at http://developingchild.harvard.edu/

Tomas J. Aragon, MD, DrPH (SFDPH) Roots of Adult Health Inequities NACCHO, July, 2016 7 / 16

The Production of Trauma from ViolenceAdverse Community Experiences and Resilience—The Prevention Institute

Tomas J. Aragon, MD, DrPH (SFDPH) Roots of Adult Health Inequities NACCHO, July, 2016 8 / 16

The Kresge-inspired SFDPH LEAD InitiativePublic health leadership is “the practice of mobilizing people, organizations, andcommunities to effectively tackle tough public health challenges” (Begun & Malcolm)

Adpated from the Lean Transformation Framework(http://www.lean.org/WhatsLean/TransformationFramework.cfm)

Tomas J. Aragon, MD, DrPH (SFDPH) Roots of Adult Health Inequities NACCHO, July, 2016 9 / 16

Core Principles of Trauma-Informed Systems

We serve diverse, traumatized communities under chronic, toxic stress.Our diverse staff also come from these communities. Therefore, we needto 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.

Tomas J. Aragon, MD, DrPH (SFDPH) Roots of Adult Health Inequities NACCHO, July, 2016 10 / 16

Cultural/Racial HumilityAdapted Melanie Tervalon, Jann Murray-Garcıa, and Kenneth Hardy

In 1998, Melanie Tervalon and Jann Murray-Garcıa published agroundbreaking article that challenged the concept of “culturalcompetency” with the concept of “cultural humility.” Cultural humility iscommitting to lifelong learning, critical self-reflection, and personal andinstitutional transformation.

1 Commit to lifelong learning and critical self-reflection

2 Realize our own power, privilege, and prejudices

3 Cultivate humility and empathy for respectful partnerships

4 Acknowledge and validate our common humanity

5 Practice humble inquiry and deep listening

6 Promote institutional accountability

Tomas J. Aragon, MD, DrPH (SFDPH) Roots of Adult Health Inequities NACCHO, July, 2016 11 / 16

Black/African American Health Initiative, April, 2014San Francisco Health Network (SFHN)

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 Women’s Health (focus: breast cancer)

4 Sexual Health (focus: Chlamydia)

Tomas J. Aragon, MD, DrPH (SFDPH) Roots of Adult Health Inequities NACCHO, July, 2016 12 / 16

Trauma-Informed Community Building (San Francisco)

TRAUMA INFORMED COMMUNITY BUILDINGA 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 PEOPLE Model for Community Health ImprovementInspired by The Prevention Institute’s Adverse Community Experiences and Resilience

P = People,

E = Equitable

O Opportunity,

P = Place, and

L = Life course

E Equity

Tomas J. Aragon, MD, DrPH (SFDPH) Roots of Adult Health Inequities NACCHO, July, 2016 14 / 16

The PEOPLE Model for Community Health ImprovementInspired by The Prevention Institute’s Adverse Community Experiences and Resilience

Tomas J. Aragon, MD, DrPH (SFDPH) Roots of Adult Health Inequities NACCHO, July, 2016 15 / 16

Review

Foundational themes

1 Life-course of structural racism,discrimination, and chronicstress

2 Individual and communitiessuffer from the effects of trauma

3 The effects of trauma aretransmitted across generations

4 Toxic stress effects child brain,body, and behavior for life

Tomas J. Aragon, MD, DrPH (SFDPH) Roots of Adult Health Inequities NACCHO, July, 2016 16 / 16