Structural Trauma and Toxic Stress:Lifecourse Roots of Health InequitiesInterdepartmental Grand Rounds, Kaiser Permanente

Tomás J. Aragón, MD, DrPHAugust 31, 2016

Health Officer, City & County of San FranciscoDirector, Population Health DivisionSan Francisco Department of Public HealthAdjunct Faculty, UC Berkeley School of Public Healthhttp://populationhealth.science (blog)tomas.aragon@sfdph.org (email)

Outline

1. How do we explain racial/ethnic health inequities?

2. San Francisco Department of Public Health

3. San Francisco Community Health Needs Assessment, 2016

4. Structural trauma and toxic stress—The lifecourse roots of health inequities

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1. How do we explain racial/ethnichealth inequities?

Causes of premature deaths in men and women, San Francisco, 2003–2004How do we explain racial/ethnic health inequities and resilience?

footnoteAge-adjusted Expected Years of Life Lost (eYLL): Male (left), Female (right); © Black (colored red),4 Latino, × Asian/PI, + White; Source: Aragón TJ, et al. PubMed ID: 18402698 2

2. San Francisco Department ofPublic Health

Organization Chart, San Francisco Department of Public Health (SFDPH)

San Francisco Health Commission (7 members)Barbara Garcia, MPA, Director of Health

San Francisco Health Network (SFHN) (96%) Population Health Division (PHD) (4%)Roland Pickens, Director Tomás Aragón, Director & Health OfficerAmbulatory Care Environmental Health- Primary Care (4%) Community Health Equity and Promotion- Behavioral Health (18%) Disease Prevention and Control- Maternal, Child, and Adolescent Health Emergency Preparedness and Response- Jail Health (2%) Emergency Medical ServicesZuckerberg SF General (44%) Epidemiology and SurveillanceLagunda Honda Hospital (12%) Center for Learning and InnovationTransitions Center for Public Health Research

Bridge HIV (Research)Office of Health Equity and Planning

Administration

Source: https://www.sfdph.org/dph/files/reports/PolicyProcOfc/SFDPH-AnnualReport-2014-2015.pdf

3

Patient Distribution by Payer Source, SF Health Network, SFDPH

Primary Care and Behavioral Health Patients by Payer Source, FY 2014–2015

Hospital Patients by Payer Source, FY 2014–2015

4

Patients by Race/Ethnicity, SF Health Network, SFDPH, FY 2014-2015

Source: https://www.sfdph.org/dph/files/reports/PolicyProcOfc/SFDPH-AnnualReport-2014-2015.pdf

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3. San Francisco Community HealthNeeds Assessment, 2016

San Francisco Framework for Assessing Population Health and Equity

Healthis a state of complete physical, mental and socialwell-being and not merely the absence of disease orinfirmity (WHO 1946).

Public Healthis what we, as a society, do collectively to assurethe conditions in which people can be healthy(IOM 1988).

Population Healthis a systems framework for studying and improvingthe health of populations through collective actionand learning (Source: http://phds.io).

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San Francisco Community Health Needs Assessment, 2016 (www.sfhip.org)

Demographics Health Outcomes - Sexual HealthCommunity Identified Priorities - Asthma and COPD - Substance AbusePopulation Health Framework - Cancer - TobaccoSocial Determinants of Health - Cardiovascular Disease and Stroke - Tuberculosis- Civic Participation - Children’s Oral Health - Vaccine Preventable Disease- Education and Childcare - Diabetes - Weight- Economic Environment - Food-borne Disease - Nutrition- Health Care Assess and Quality - Health and Well-being - Physical Activity- Housing - Hepatitis B and C - Preterm Births- Natural Environment - Influenza and Pneumonia - Sexual Health- Transportation - Mental Health - Substance Abuse- Safety - Mortality - Tobacco

- Nutrition - Tuberculosis- Physical Activity - Vaccine Preventable Disease- Preterm Births - Weight

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Left: Age pyramid, San Francisco, 2009–2013Right: Population projections by age, San Francisco, 2010–2060

Source: San Francisco Community Health Needs Assessment (http://sfhip.org) 8

Left: Population distribution, SF, 2010 vs. 2030, andRight: Population change by race/ethnicity, 1970–2013

Source: San Francisco Community Health Needs Assessment (http://sfhip.org) 9

Leading causes of premature deaths, Males, San Francisco, 2010–2013

Source: San Francisco Community Health Needs Assessment (http://sfhip.org) 10

Leading causes of premature deaths, Females, San Francisco, 2010–2013

Source: San Francisco Community Health Needs Assessment (http://sfhip.org) 11

Adult asthma hospitalization rates, by race/ethnicity, San Francisco, 2005–2014

Source: San Francisco Community Health Needs Assessment (http://sfhip.org)

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Cancer mortality rates, by race/ethnicity, San Francisco, 2009–2012

Source: San Francisco Community Health Needs Assessment (http://sfhip.org) 13

Invasive cancers incidence rates, by ethnicity, San Francisco, 2008-2012

Source: San Francisco Community Health Needs Assessment (http://sfhip.org) 14

Left: Hospitalization rates due to hypertension, San Francisco, 2006–2014Right: Hospitalization rates due to heart failure, San Francisco, 2005–2013

Source: San Francisco Community Health Needs Assessment (http://sfhip.org)

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San Francisco Unified School District, Annual high school graduation,2009–2010 to 2014-2015

Academic Year

Gra

duat

ion

Perc

ent

020

4060

8010

0

2009-2010 2010-2011 2011-2012 2012-2013 2013-2014 2014-2015

LatinoAsianPacific Island.FilipinoBlack/AfrAmWhite

Source: California Department of Education, Data Quest http://dq.cde.ca.gov/dataquest/ 16

Children (ages 0–17 years) with Child Maltreatment Substantiations,San Francisco, Incidence per 1,000 children

2000 2005 2010 2015

010

2030

4050

60

Year

Rate

per

100

0 ch

ildre

n

BlackWhiteLatinoAsianPI

Source: California Child Welfare Indicators Project http://cssr.berkeley.edu/ucb_childwelfare/ 17

San Franciscans do not have equal opportunity for good healthUnevenly distributed obstacles to health (left); Health inequities (right)

Source: San Francisco Community Health Needs Assessment (http://sfhip.org) 18

4. Structural trauma and toxicstress—The lifecourse roots ofhealth inequities

The lifecourse roots of health and well-being, 2004–2016

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Structural trauma and toxic stress—The roots of health inequities

Foundational themes

• Life-course of toxic stress, structural racism, and discrimination• Individual and communities suffer from the effects of trauma• The effects of trauma are transmitted across generations• Toxic stress effects child brain, body, and behavior for life

Trauma-informed approaches in San Francisco

• Trauma-informed systems training (Bay Area)• Trauma-Informed Community Building (TICB)• Black/African American Health Initiative (BAAHI)• Healthy Hearts San Francisco (CDC REACH grant)• Our Children, Our Families (collective impact)• San Francisco Health Improvement Partnership (sfhip.org)

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Childhood adversities and mental health outcomes in homeless adultsSan Francisco, 2016 (Am J Geriatr Psychiatry 2016)

Source: http://www.centerforyouthwellness.org/ 21

Neural connections and neuroplasticity in the early and late years of life

Source: http://developingchild.harvard.edu

22

Lifecourse Health Development—Variable trajectories

Source: Halfon N, Larson K, Lu M, Tullis E, Russ S. Lifecourse health development: past, present andfuture. Matern Child Health J. 2014;18(2):344-65. PubMed PMID: 23975451 23

How our core capabilities workAutomatic and intentional self-regulation, attention, and executive function

Executive function skill proficiency

Source: http://www.developingchild.harvard.edu 24

The lifecourse health development of adult inequitiesRe-conceptualizing early lifecourse policies to strengthen lifelong health

Source: Center for the Developing Child at http://developingchild.harvard.edu/ 25

Adverse Community Experiences and Resilience:A Framework for Addressing and Preventing Community Trauma

From The Prevention Instituteand Kaiser Permanente, 2015 26

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

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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Black/African American Health Initiative, April, 2014Lead: Dr. Ayanna Bennett, San Francisco Department of Public Health

BAAHI components

1. Collective impact2. Workforce development3. 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)

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Hypertension Control Dashboard, Primary Care Hypertension Equity InitiativeLead: Dr. Ellen Chen and Kimberly Puccetti, Primary Care, San Francisco Health Network

Dec Feb Apr Jun Aug Oct Dec

0%

50%

100%

% Patients With Controlled BP

0 Patients Needed

Total: 60%

AA: 58%

58%

CMHC

Dec Feb Apr Jun Aug Oct Dec

4 Patients Needed

Total: 81%

AA: 62%

78%

CPHC

Dec Feb Apr Jun Aug Oct Dec

7 Patients Needed

Total: 71%

AA: 58%63%

CSC

Dec Feb Apr Jun Aug Oct Dec

19 Patients Needed

Total: 67%

AA: 60%

65%

FHC

Dec Feb Apr Jun Aug Oct Dec

0%

50%

100%% Patients With Controlled BP

40 Patients Needed

Total: 69%

AA: 63%

70%

RFPC

Dec Feb Apr Jun Aug Oct Dec

21 Patients Needed

Total: 70%

AA: 66%

71%

MHHC

Dec Feb Apr Jun Aug Oct Dec

0 Patients Needed

Total: 74%

AA: 72%

67%

OPHC

Dec Feb Apr Jun Aug Oct Dec

17 Patients Needed

Total: 69%

AA: 67%

75%

PHP

Dec Feb Apr Jun Aug Oct Dec

0%

50%

100%

% Patients With Controlled BP

7 Patients Needed

Total: 65%

AA: 62%

64%

PHHC

Dec Feb Apr Jun Aug Oct Dec

12 Patients Needed

Total: 68%

AA: 54%

60%

SAFHC

Dec Feb Apr Jun Aug Oct Dec

0 Patients Needed

Total: 62%

AA: 62%

61%

SEHC

Dec Feb Apr Jun Aug Oct Dec

73 Patients Needed

Total: 59%

AA: 54%

65%

TWUHC

LEGEND: Total Hypertensive Population Black Hypertensive Population Patients Needed to Reach Goal Black BP Control Goal

True North: Quality & EquityPrimary Care Driver Metric: HTN Equity

Black Hypertensive Patient Population

Dec Feb Apr Jun Aug Oct Dec

0%

50%

100%

% Patients With Controlled BP

169 Patients Needed

PC Total: 68%

PC AA: 61%

65%

SFHN PC TUHC670

SEHC969

SAFHC194

RFPC588

PHP203

PHHC348

OPHC

MHHC423

FHC391

CSC141

4,122

SFHNPC

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Healthy Hearts SF—Prescriptions for free physical activity in the communityLead: Jacque McCright, Community Health Equity and Promotion, Population Health Division

URL: https://www.facebook.com/HealthyHeartsSF/Video: https://youtube.com/watch?v=aZIjTSfc2lk

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LEAD Initiative, San Francisco Department of Public HealthLead: Barbara Garcia, and inspired by the Kresge Emerging Leaders in Public Health

Adapted from the Lean Transformation Framework (http://www.lean.org) 31

Core principles of trauma-informed systemsSFDPH initiative lead by Dr. Kenneth Epstein

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

1. Understanding trauma and stress2. Compassion and dependability3. Safety and stability4. Collaboration and empowerment5. Cultural humility and responsiveness6. Resilience and recovery

For more information visit: http://www.t2bayarea.org.32

Cultural/Racial Humility

In 1998, Melanie Tervalon and Jann Murray-García published a groundbreaking articlethat challenged the concept of “cultural competency” with the concept of “culturalhumility.” Cultural humility1 is committing to lifelong learning, critical self-reflection,and personal and institutional transformation.

1. Commit to lifelong learning and critical self-reflection.2. Cultivate humility,2 opening our hearts to transformation.3. Realize our own power, privilege, and prejudices.4. Redress power imbalances for respectful partnerships.5. Recognize and validate our common humanity.6. Promote institutional accountability.

1Adapted from Drs. Melanie Tervalon, Jann Murray-García, and Kenneth Hardy2“Humility is the noble choice to forgo your status and use your influence for the good of others. It isto hold your power in service of others.” (Source: John Dickson, Humilitas, http://a.co/gV1cldW)

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The PEOPLE model for community health improvementInspired by The Prevention Institute’s Adverse Community Experiences and Resilience

P = People,E = EquitableO Opportunity,P = Place, andL = Life courseE Equity

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The PEOPLE model for community health improvementInspired by The Prevention Institute’s Adverse Community Experiences and Resilience

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The PEOPLE model for community health improvementInspired by The Prevention Institute’s Adverse Community Experiences and Resilience

• Life-course of toxic stress, structuralracism, and discrimination

• Individual and communities sufferfrom the effects of trauma

• The effects of trauma are transmittedacross generations

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

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QUESTIONS?Acknowledgments (in alphabetical order)

Abbie Yant, Alice Chen, Amor Santiago, Aneeka Chaudhry, Ayanna Bennett, Barbara A Garcia,Barry Lawlor, Belle Taylor-McGhee, Brittney Doyle, Cecilia Thomas, Christine Siador, CindyGarcia, Colleen Chawla, Colleen Matthews, Curtis Chan, Darlene Daevu, David Serrano Sewell,Deborah Sherwood, Deena Lahn, 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 Fuchs,Judith Martin, Karen Pierce, Kenneth Epstein, Kenneth Hardy, Kevin Grumbach, Kim Shine,Kirsten Bibbins-Domingo, Leigh Kimberg, Lisa Golden, Maria X Martinez, Marlo Simmons,Mary Hansell, Michelle Albert, Michelle Kirian, Michelle Long, Muntu Davis, Nadine BurkeHarris, Patricia Erwin, Paula Fleisher, Perry Lang, Rachael Kagan, Rhea Bailey, RhondaSimmons, Roberto Vargas, Robin George, Roland Pickens, Ron Weigelt, Stuart Fong, SusanEhrlich, Susan Philip, Tessa Rouverol Collejo, Thomas Boyce, Tracey Packer, VeronicaShepard, Wanda Materre, Wanetta Davis, Wylie Liu

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