Hope in a Hidden Public Health Crisis

Photo: Getty Images/Scott Olson.
A memorial for a 14-year-old boy murdered in Chicago in 2013. Photo: Getty Images/Scott Olson.

LaVerne Vaughn made a decision after she served prison time in her late 30s: She’d live the rest of her life a free woman. Vaughn, now in her early 40s, with a platinum pixie cut and a steady, empathetic gaze, kept her promise to herself. Several years after her release, she started working in violence prevention and helping ex-cons in Richmond, Calif., find their footing after prison.

Vaughn’s life isn’t crime-free, despite her successful turnaround. She sees violence on a regular basis, both as a resident of Richmond and in her work for the Office of Neighborhood Safety, the city agency charged with preventing homicides. Richmond, a city of 100,000, is known for its high homicide rate. Guns are the weapons of choice. Comforting mothers whose children have been murdered or maimed by gunfire is part of what Vaughn does. Asked if her work is difficult, she replies softly: “Sometimes. Sometimes it is.”

Violence prevention workers in the city face a daunting task. Drive-by shootings are routine, shootings sometimes claim innocent bystanders, and few murders are solved. The homicide rate has soared to nine times the national average twice in the past decade. During one of those especially tragic years, 2006, the city was desperate. That year residents built tent cities in high crime areas in their own attempt to make the streets safe. In 2007 the city opened the Office of Neighborhood Safety.

“They used to talk about calling in the National Guard, [saying] ‘we have to do something for desperate young people on the streets,’” recalls former Mayor Gayle McLaughlin, who led the city from 2006 to 2014.

The Office of Neighborhood Safety has significantly helped lower the homicide rate, but the streets of Richmond remain dangerous. Vaughn says that living amid danger and grief causes her stress on a daily basis. “Even if it’s not conscious, it is eating away at you, eating away at you,” she says. “Every time you go outside, you’re afraid something is going to happen to you.”

A movement is under way in California and across the country to acknowledge that living in high-stress, dangerous environments, such as Vaughn’s neighborhood, is a risk factor for illness and preventable death. Trauma is a public health crisis, advocates say, one that hides in plain sight—and shaves years off the lives of people in high-poverty and high-crime neighborhoods.

Toxic Stress

The poorest residents of Contra Costa County, which includes Richmond, can expect to live about 75 years. The life expectancy for the county’s wealthiest residents is slightly more than 81 years. Nationally, life span differs by education level, a measure of socioeconomic status. Men who finished college live nine years longer than men who didn’t finish high school; for women, the difference is five years.

One cause of these disparities in life span may be the kind of prolonged stress felt by Vaughn and others who live in areas prone to violence. Trauma isn’t limited to one income bracket, but low-income people tend to report seeing and experiencing traumatic events at younger ages and more frequently. About 20 percent of people who live below the poverty line report having survived four or more traumatic experiences, compared to 13 percent of wealthier people.

This statistic doesn’t surprise Vaughn. “When I was younger, in my 20s, it seemed like a homicide every day. It got to a place where we were having some 40 homicides a year,” Vaughn recalls. “Out of my close friends, there are only a handful of us left that are still alive or not in prison.”

Also a young mother then, she had difficulty parenting through the emotional crises that followed those losses. “It left me numb for a long time.”

Crimes like homicide affect people of color disproportionately, especially in communities with higher levels of poverty, like Richmond. Homicide is the second leading cause of death for young African Americans and the sixth leading cause of death overall for African Americans. For other Americans, gun violence doesn’t rate among the top 10 killers.

Nadine Burke Harris is at the forefront of the movement to recognize that living with violence hurts long-term health. She started observing the health effects of trauma as a pediatrician at a clinic in Bayview-Hunters Point, an impoverished San Francisco neighborhood that sees many of the city’s homicides. Her patients experienced terrible events, she explained at the Children Can Thrive conference last November. They saw “shootings in their neighborhood, neighbors who broke into their houses and stole their things… family members being arrested right in front of them.”

Burke Harris, drawing on a field of study called the biology of adversity, came to believe that these events caused the poor health that many of her patients were likely to experience in adulthood. Life in these tough neighborhoods can change the fundamentals of the body: causing the heart to beat faster, blood pressure to rise and hormone levels to spike and drop suddenly.

Traumatic events also shape the brain and its decision-making capacity. “In the moment when stress hormones are activated and you have to decide—fight or flight?—what your brain rightly does is disengage your prefontal cortex,” Burke Harris explains. “So your judgment function, your critical thinking function, your executive function gets downregulated, and your amygdala, which regulates your fear response, gets upregulated. Not only are you priming your body to do this—you are also priming your brain to do this.”

These stress responses are helpful: It’s useful to be afraid of a bear in the woods. But without periods of relaxation, the brain’s wiring can change. Continual stress isn’t good for long-term health and contributes to conditions such as heart disease, stroke, cancer, type 2 diabetes and depression.

Behaviors also play a role in damaging long-term health. Neuroscientist Bruce McEwan, a pioneer in the field of the biology of adversity, says that risky health behaviors like smoking and traumatic life experiences merge into a “perfect storm.” Together, they cause what’s termed toxic stress. “Normally the cortisol stress response or heart rate stress response gets turned on when it’s needed and turned off again when it’s no longer needed,” McEwan explains. “When people are under [continual] stress and when they begin to show some of these health-damaged behaviors, these systems will often stay on.”

But dangerous choices about health, Burke Harris adds, are not a sufficient explanation for differences in rates of disease and average life span. “If you don’t smoke, if you don’t engage in any high-risk behavior,” she explains, “you still are at almost twice the risk for heart disease [if you are exposed to traumatic experiences].”

Trauma, it turns out, has what’s called a dose effect: The less you have, the better your health. Conversely, the more you have, the worse you’ll fare. Landmark research conducted by Vincent Felitti and Robert Anda, published in 1998, first suggested a connection between adverse experiences and health. Felitti and Anda defined adverse childhood experiences, or ACE, as 12 specific experiences that fall within one of three headings: abuse, neglect or family dysfunction. Under these headings are emotional, physical and sexual abuse, witnessing domestic violence, parental separation or divorce, and growing up with household members who were mentally ill, substance abusers or sent to prison.

Their findings are startling: People with six or more ACE lose 20 years of life compared to people with none.

“For a person who has an ACE score of seven or more, the risk of ischemic heart disease is 350 percent higher than for a person with no ACE,” Burke Harris explains. “That’s more than if you are a smoker, that’s more than if you have high cholesterol, that’s more than if you have high blood pressure.”

Adverse childhood experiences have been measured since 2008 as part of a larger health survey conducted by the California Department of Public Health. “A Hidden Crisis,” the report released in conjunction with the Children Can Thrive conference and co-authored by the Center for Youth Wellness, is drawn from the first results.

Those findings were startling, too. For people who had four or more adverse experiences, the relative risk of heart disease was 220 percent. Their risk of depression was 460 percent higher than for those who had no adverse childhood experiences. Women with four or more of the childhood traumas had double the risk of miscarriage.

The results, Vaughn says, are visible. She describes life in Richmond as being among the walking wounded. “I think every single person who lives in an urban community that is plagued by violence has some form of PTSD [post-traumatic stress disorder].”

The Resilience Cure

Though toxic stress is damaging, it is treatable, Burke Harris says. The first step is properly assessing the disease risk of patients when they come to the doctor’s office by understanding the traumas they have faced in their early years. Burke founded the Center for Youth Wellness, a clinic that routinely screens patients for traumatic experiences that can cause later chronic illnesses. The center, opened in Bayview-Hunter’s Point in 2007, is nationally known for its innovative approach.

The regularity of childhood trauma seems dispiriting, but Burke Harris says that the studies of childhood adversity actually gave her more hope for the health of her patients. Finally, she says, there was an explanation for what was making them sicker than other children. “When I saw the information about how early adversity is so directly connected to health outcomes, it was something I felt I was seeing every day in my patients.”

She adds: “It was like the clouds parted.”

Burke Harris is not the only doctor who sees hope in what’s called a trauma-informed approach to health care, one that understands terrible experiences as a lifelong influence on health.

John Rich saw young people who had been shot or stabbed leave the hospital with no follow-up care during his years practicing medicine at Boston’s City Hospital. Many suffered from aftereffects including post-traumatic stress. Returning to a normal life, going back to school, work and everyday responsibilities, was difficult for crime victims. But dropping out of education and employment could spell disaster for the emotional and economic future of crime victims, compounding the “perfect storm” that McEwan described.

Moreover, Rich says, crime victims are often hypervigilant and defensive, seeing danger everywhere and preparing to respond to another assault. To make this point at a 2013 Institute of Medicine panel on violence and public health, Rich shared the story of David, a young man he met while writing his book, Wrong Place, Wrong Time: Trauma and Violence in the Lives of Young Black Men.

The first time David saw someone shot, he was playing basketball with his friends. “It was random,” he tells Rich in a short video. “I never thought anything like that would happen to me.” Then David’s cousin was shot while sleeping in his own bed. David started sleeping during the day rather than at night. He would have nightmares and wake up crying. Then his brother was shot. “I was sitting in the street with my brother’s head in my lap. My brother just wanted me to hold him.”

David knew he was next. “I started practicing how I hold myself so the bullet would hit my shoulder, not my heart.” His fear came true when he was shot three times.

Rich launched several programs to help young men like David. He founded the Young Men’s Health Clinic in Boston to offer ongoing care for patients from low-income areas, who are disproportionately likely to be crime victims. Rich won a MacArthur genius award for that work in 2006. After he wrote Wrong Place, Wrong Time, he went on to develop a program in Philadelphia to help gunshot victims recover from their emotional wounds, called Healing Hurt People.

Healing Hurt People, directed by emergency room doctor Ted Corbin, connects hospital patients treated for intentionally inflicted wounds to social services. David was one of those patients. Program participants get a range of support, including help with housing, mentoring and substance abuse treatment. Those services may be crucial to their survival. More than 20 percent of victims, Rich notes, will die within five years of their injury if left unaided.

Many participants in Healing Hurt People suffer from post traumatic stress, so the program also provides emotional support. Part of what Healing Hurt People does is help victims shore up their emotional resources and build their resilience. Some are better equipped to recover from painful events because of their circumstances or personality. Having a caring, involved adult, or a personality trait like confidence, makes some more resilient than others.

“We think about resilience not as an inborn, innate attribute, like some people have it and some people don’t,” Rich explains. “At any given point in time, your resilience or resistance to trauma will be different. If you have resources, like the ability to calm yourself, and confidence, then you may be able to withstand these things more than people without them.”

Skills like coping are easiest to acquire before the age of 5, when the developing mind is at its most plastic. But, Burke Harris notes, “synaptic plasticity occurs across a lifetime.” In other words, learning happens throughout life. Though the process of changing fundamental behaviors like coping mechanisms is more difficult for older children and adults, it is very possible.

Understanding trauma and its health effects as manageable problems may be critical to extending the lives and improving the health of people who live in low-income, high-violence communities. The key, LaVerne Vaughn says, is to have help available for those who need it. Right now, there are too few resources. Lives that might be salvaged may be lost. The message in this lack of resources is that some lives don’t matter, a message that Vaughn refuses to accept. “There is no such thing,” Vaughn says, “as throwaway people.”

First in a series of three stories about violence as a public health crisis.


Stopping Homicides, One Shooter at a Time
Why Young People Kill

The John Jay/Tow Foundation Juvenile Justice Reporting Fellowship helped to support this series.

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