AS I WALKED INTO an exam room at the Bayview Child Health Center to meet my next patient, I couldn’t help but smile. My team and I had worked hard to make the clinic as inviting and family-friendly as possible. The room was painted in pastel colors and had a matching checkered floor. Cartoons of baby animals paraded across the wall above the sink and marched toward the door. If you didn’t know better, you’d think you were in a pediatric office in the affluent Pacific Heights neighborhood of San Francisco instead of in struggling Bayview, which was exactly the point. We wanted our clinic to be a place where people felt valued.
When I came through the door, Diego’s eyes were glued to the baby giraffes. What a super-cutie, I thought as he moved his attention to me, flashed me a smile, and checked me out through a mop of shaggy black hair. He was perched on the chair next to his mother, who held his three-year-old sister in her lap. When I asked him to climb onto the exam table, he obediently hopped up and started swinging his legs back and forth. As I opened his chart, I saw his birth date and looked up at him again—Diego was a cutie and a shorty.
Quickly I flipped through the chart, looking for some objective data to back up my initial impression. I plotted Diego’s height on the growth curve, then I double-checked to be sure I hadn’t made a mistake. My newest patient was at the 50th percentile for height for a four-year-old.
Which would have been fine, except that Diego was seven years old.
That’s weird, I thought, because otherwise, Diego looked like a totally normal kid. I scooted my chair over to the table and pulled out my stethoscope. As I got closer I could see thickened, dry patches of eczema at the creases of his elbows, and when I listened to his lungs, I heard a distinct wheezing. Diego’s school nurse had referred him for evaluation for attention deficit hyperactivity disorder (ADHD), a chronic condition characterized by hyperactivity, inattention, and impulsivity. Whether or not Diego was one of the millions of children affected by ADHD remained to be seen, but already I could see his primary diagnoses would be more along the lines of persistent asthma, eczema, and growth failure.
Diego’s mom, Rosa, watched nervously as I examined her son. Her eyes were fixed on Diego and filled with concern; little Selena’s gaze was darting around the room as she checked out all the shiny gadgets.
“Do you prefer English o Español?” I asked Rosa.
Relief crossed her face and she leaned forward.
After we talked—in Spanish—through the medical history that she had filled out in the waiting room, I asked the same question I always do before jumping into the results of the physical exam: Is there anything specific going on that I should know about?
Concern gathered her forehead like a stitch.
“He’s not doing well in school, and the nurse said medicine could help. Is that true? What medicine does he need?”
“When did you notice he’d started having trouble in school?” I asked.
There was a slight pause as her face morphed from tense to tearful.
“¡Ay, Doctora!” she said and began the story in a torrent of Spanish.
I put my hand on her arm, and before she could get much further, I poked my head out the door and asked my medical assistant to take Selena and Diego to the waiting room.
The story I heard from Rosa was not a happy one. She spent the next ten minutes telling me about an incident of sexual abuse that had happened to Diego when he was four years old. Rosa and her husband had taken in a tenant to help offset the sky-high San Francisco rent. It was a family friend, someone her husband knew from his work in construction. Rosa noticed that Diego became more clingy and withdrawn after the man arrived, but she had no idea why until she came home one day to find the man in the shower with Diego. While they had immediately kicked the man out and filed a police report, the damage was done. Diego started having trouble in preschool, and as he moved up, he lagged further and further behind academically. Making matters worse, Rosa’s husband blamed himself and seemed angry all the time. While he had always drunk more than she liked, after the incident it got a lot worse. She recognized the tension and drinking weren’t good for the family but didn’t know what she could do about it. From what she told me about her state of mind, I strongly suspected she was suffering from depression.
I assured her that we could help Diego with the asthma and eczema and that I’d look into the ADHD and growth failure. She sighed and seemed at least a little relieved.
We sat in silence for a moment, my mind zooming around. I believed, ever since we’d opened the clinic in 2007, that something medical was happening with my patients that I couldn’t quite understand. It started with the glut of ADHD cases that were referred to me. As with Diego’s, most of my patients’ ADHD symptoms didn’t just come out of the blue. They seemed to occur at the highest rates in patients who were struggling with some type of life disruption or trauma, like the twins who were failing classes and getting into fights at school after witnessing an attempted murder in their home or the three brothers whose grades fell precipitously after their parents’ divorce turned violently acrimonious, to the point where the family was ordered by the court to do their custody swaps at the Bayview police station. Many patients were already on ADHD medication; some were even on antipsychotics. For a number of patients, the medication seemed to be helping, but for many it clearly wasn’t. Most of the time I couldn’t make the ADHD diagnosis. The diagnostic criteria for ADHD told me I had to rule out other explanations for ADHD symptoms (such as pervasive developmental disorders, schizophrenia, or other psychotic disorders) before I could diagnose ADHD. But what if there was a more nuanced answer? What if the cause of these symptoms—the poor impulse control, inability to focus, difficulty sitting still—was not a mental disorder, exactly, but a biological process that worked on the brain to disrupt normal functioning? Weren’t mental disorders simply biological disorders? Trying to treat these children felt like jamming unmatched puzzle pieces together; the symptoms, causes, and treatments were close, but not close enough to give that satisfying click.
I mentally scrolled back, cataloging all the patients like Diego and the twins that I’d seen over the past year. My mind went immediately to Kayla, a ten-year-old whose asthma was particularly difficult to control. After the last flare-up, I sat down with mom and patient to meticulously review Kayla’s medication regimen. When I asked if Kayla’s mom could think of any asthma triggers that we hadn’t already identified (we had reviewed everything from pet hair to cockroaches to cleaning products), she responded, “Well, her asthma does seem to get worse whenever her dad punches a hole in the wall. Do you think that could be related?”
Kayla and Diego were just two patients, but they had plenty of company. Day after day I saw infants who were listless and had strange rashes. I saw kindergartners whose hair was falling out. Epidemic levels of learning and behavioral problems. Kids just entering middle school had depression. And in unique cases, like Diego’s, kids weren’t even growing. As I recalled their faces, I ran an accompanying mental checklist of disorders, diseases, syndromes, and conditions, the kinds of early setbacks that could send disastrous ripples throughout the lives to come.
If you looked through a certain percentage of my charts, you would see not only a plethora of medical problems but story after story of heart-wrenching trauma. In addition to the blood pressure reading and the body mass index in the chart, if you flipped all the way to the Social History section, you would find parental incarcerations, multiple foster-care placements, suspected physical abuse, documented abuse, and family legacies of mental illness and substance abuse. A week before Diego, I’d seen a six-year-old girl with type 1 diabetes whose dad was high for the third visit in a row. When I asked him about it, he assured me I shouldn’t worry because the weed helped to quiet the voices in his head. In the first year of my practice, seeing roughly a thousand patients, I diagnosed not one but two kids with autoimmune hepatitis, a rare disorder that typically affects fewer than three children in one hundred thousand. Both cases coincided with significant histories of adversity.
I asked myself again and again: What’s the connection?
If it had been just a handful of kids with both overwhelming adversity and poor health outcomes, maybe I could have seen it as a coincidence. But Diego’s situation was representative of hundreds of kids I had seen over the past year. The phrase statistical significance kept echoing through my head. Every day I drove home with a hollow feeling. I was doing my best to care for these kids, but it wasn’t nearly enough. There was an underlying sickness in Bayview that I couldn’t put my finger on, and with every Diego that I saw, the gnawing in my stomach got worse.
For a long time the possibility of an actual biological link between childhood adversity and damaged health came to me as a question that lingered for only a moment before it was gone. I wonder . . . What if . . . It seems like . . . These questions kept popping up, but part of the problem in putting the pieces together was that they would emerge from situations occurring months or sometimes years apart. Because they didn’t fit logically or neatly into my worldview at those discrete moments in time, it was difficult to see the story behind the story. Later it would feel obvious that all of these questions were simply clues pointing to a deeper truth, but like a soap-opera wife whose husband was stepping out with the nanny, I would understand it only in hindsight. It wasn’t hotel receipts and whiffs of perfume that clued me in, but there were plenty of tiny signals that eventually led me to the same thought: How could I not have seen this? It was right in front of me the whole damn time.
I lived in that state of not-quite-getting-it for years because I was doing my job the way I had been trained to do it. I knew that my gut feeling about this biological connection between adversity and health was just a hunch. As a scientist, I couldn’t accept these kinds of associations without some serious evidence. Yes, my patients were experiencing extremely poor health outcomes, but wasn’t that endemic to the community they lived in? Both my medical training and my public-health education told me that this was so.
That there is a connection between poor health and poor communities is well documented. We know that it’s not just how you live that affects your health, it’s also where you live. Public-health experts and researchers refer to communities as “hot spots” if poor health outcomes on the whole are found to be extreme in comparison to the statistical norm. The dominant view is that health disparities in populations like Bayview occur because these folks have poor access to health care, poor quality of care, and poor options when it comes to things like healthy, affordable food and safe housing. When I was at Harvard getting my master’s degree in public health, I learned that if I wanted to improve people’s health, the best thing I could do was find a way to provide accessible and better health care for these communities.
Straight out of my medical residency, I was recruited by the California Pacific Medical Center (CPMC) in the Laurel Heights area of San Francisco to do my dream job: create programs specifically targeted to address health disparities in the city. The hospital’s CEO, Dr. Martin Brotman, personally sat me down to reinforce his commitment to that. My second week on the job, my boss came into my office and handed me a 147-page document, the 2004 Community Health Assessment for San Francisco. Then he promptly went on vacation, giving me very little direction and leaving me to my own ambitious devices (in hindsight, this was either genius or crazy on his part). I did what any good public-health nerd would do—I looked at the numbers and tried to assess the situation. I had heard that Bayview Hunters Point in San Francisco, where much of San Francisco’s African American population lived, was a vulnerable community, but when I looked at the 2004 assessment, I was floored. One way the report grouped people was by their zip code. The leading cause of early death in seventeen out of twenty-one zip codes in San Francisco was ischemic heart disease, which is the number-one killer in the United States. In three zip codes it was HIV/AIDS. But Bayview Hunters Point was the only zip code where the number one cause of early death was violence. Right next to Bayview (94124) in the table was the zip code for the Marina district (94123), one of the city’s more affluent neighborhoods. As I ran my finger down the rows of numbers, my jaw dropped. What they showed me was that if you were a parent raising your baby in the Bayview zip code, your child was two and a half times as likely to develop pneumonia than a child in the Marina district. Your child was also six times as likely to develop asthma. And once that baby grew up, he or she was twelve times as likely to develop uncontrolled diabetes.
I had been hired by CPMC to address disparities. And, boy, now I saw why.
Looking back, I think it was probably a combination of naïveté and youthful enthusiasm that spurred me to spend the two weeks that my boss was gone drawing up a business plan for a clinic in the heart of the community with the greatest need. I wanted to bring services to the people of Bayview rather than asking them to come to us. Luckily, when my boss and I gave the plan to Dr. Brotman, he didn’t fire me for excessive idealism. Instead, he helped me make the clinic a reality, which still kind of blows my mind.
The numbers in that report had given me a good idea of what the people of Bayview were up against, but it wasn’t until March of 2007, when we opened the doors to CPMC’s Bayview Child Health Center, that I saw the full shape of it. To say that life in Bayview isn’t easy would be an understatement. It’s one of the few places in San Francisco where drug deals happen in plain sight of kindergartners on their way to school and where grandmas sometimes sleep in bathtubs because they’re afraid of stray bullets coming through the walls. It’s always been a rough place and not only because of violence. In the 1960s, the U.S. Navy decontaminated radioactive boats in the shipyard, and up until the early 2000s, the toxic byproducts from a nearby power plant were routinely dumped in the area. In a documentary about the racial strife and marginalization of the neighborhood, writer and social critic James Baldwin said, “This is the San Francisco that America pretends does not exist.”
My day-to-day experience working in Bayview tells me that the struggles are real and ever present, but it also tells me that’s not the whole story. Bayview is the oily concrete you skin your knee on, but it’s also the flower growing up between the cracks. Every day I see families and communities that lovingly support each other through some of the toughest experiences imaginable. I see beautiful kids and doting parents. They struggle and they laugh and then they struggle some more. But no matter how hard parents work for their kids, the lack of resources in the community is crushing. Before we opened the Bayview Child Health Center, there was only one pediatrician in practice for over ten thousand children. These kids face serious medical and emotional problems. So do their parents. And their grandparents. In many cases, the kids fare better because they are eligible for government-assisted health insurance. Poverty, violence, substance abuse, and crime have created a multigenerational legacy of ill health and frustration. But still, I believed we could make a difference. I opened my practice there because I wasn’t okay with pretending the people of Bayview didn’t exist.
Patients like Diego and Kayla were exactly why I came to Bayview. For as long as I could remember, I knew this was the problem I wanted to focus on, the type of community I wanted to serve. I had gotten the best medical education I could, earned a master’s in public health, and was well trained in how to work with vulnerable communities to improve access to health care. After years of schooling, I had faith in the dominant academic view: if you improve people’s access to quality health care, you will move the needle toward better health. I knew what boxes to check and I was ready to go. When I first got to Bayview, I thought all I had to do was put it in motion—start giving people great care, make it easy for them to get it affordably, and watch that needle move toward healthier kids. It seemed simple enough.
There was some pretty basic care that we could quickly implement, and by employing standardized clinical protocols, our clinic was able to dramatically improve outcomes on some things, like increasing immunization rates and decreasing asthma hospitalizations. So I was feeling pretty good for a while. But then, as I was handing out vaccines and inhalers, I started to wonder: If we were doing everything right, why didn’t we see any indication that we could make a dent in this community’s dramatically reduced life expectancy? My patients kept coming back with high rates of illnesses, and I had the sinking feeling that when they grew up, their kids would keep coming back too. Despite the checked boxes, despite the great care, and despite more health-care access than the community had seen in a generation—the needle in Bayview only bounced.
After my medical assistant had taken Diego and his sister into the waiting room and Rosa had told me some of his history, the two of us sat momentarily with our thoughts. I could only imagine the guilt, worry, and hope swimming around in her head. Regardless of our individual thought soups, both of our faces cracked into helpless smiles when Diego slid through the door, cross-eyed and goofy. Rosa stood up and I took note of her size. She was a stout woman, but height-wise, she wasn’t below the range of normal. Diego, however, was so small that he did not even come close to the growth curve for a seven-year-old boy. I remember mentally clicking through the protocol for evaluation and treatment of growth failure. Which makes sense; that’s what doctors do. You see a problem—abnormal development or disease—and you try to right the ship. But this time a simple question surfaced: What am I missing?
There is a widely known parable that students all learn on day one in public-health school, and it happens to be based on a true story. In late August 1854, there was a severe cholera outbreak in London. The Broad Street area in Soho was the epicenter, with a hundred and twenty-seven dead in the first three days and more than five hundred dead by the second week of September. Back then the dominant theory was that diseases like cholera and bubonic plague were spread through unhealthy air. John Snow, a London physician, was skeptical of this “miasma theory” of disease. By canvassing the residents of the Broad Street neighborhood, he was able to deduce the pattern of the disease. Incidences were all clustered around a water source: a public well with a hand pump. When Snow convinced local officials to disable the well by removing the pump’s handle, the outbreak subsided. At the time, no one wanted to accept Snow’s hypothesis that the disease was spread not through the air but by the more unpleasant fecal-oral route, but a few decades later, science would catch up to him, and the miasma theory would be replaced by germ theory.
As budding public-health crusaders, my classmates and I focused on the sexy part of the parable of the well, the bit where Snow topples the miasma theory. But I also took away a larger lesson: If one hundred people all drink from the same well and ninety-eight of them develop diarrhea, I can write prescription after prescription for antibiotics, or I can stop and ask, “What the hell is in this well?”
I had been about to walk past the well to do the standard evaluation for Diego’s growth failure, but this time something made me think about the case in front of me a little differently. Maybe it was the extreme presentation. Maybe I had finally seen enough cases to start putting the pieces together. Whatever the reason, I couldn’t get away from the nagging feeling that Diego’s terrible trauma and his health problems weren’t just a coincidence.
But before I could look into the well for the answer to Diego’s, or any of my patients’, problems, I needed a few more data points. The first step in Diego’s case was to order a bone-age study, an x-ray of the left wrist that can be used to determine a child’s skeletal maturation based on the size and shape of the bones. After drawing some labs and requesting his growth charts from the clinic where he had previously been seen, I handed Rosa the order form for the x-ray and sent my newest patient on his way.
Days later, I received the report from the radiologist. It confirmed that Diego’s skeletal maturity was consistent with that of a four-year-old. But Diego’s labs didn’t show low levels of growth hormone or any other hormone that might account for why he wasn’t growing. I had some important data in front of me: The trauma had happened at age four and he had gained very little vertical height since then. He also had the bone age of a four-year-old. But by all accounts, Diego wasn’t malnourished and didn’t have any evidence of a hormonal disorder. There didn’t seem to be a readily available medical explanation for Diego’s stature.
My next call was to Dr. Suruchi Bhatia, a pediatric endocrinologist at California Pacific Medical Center. I sent her the x-ray report and Diego’s labs and asked whether she thought the sexual assault of a four-year-old could lead to that child’s growth arrest.
“Is that even something you’ve seen before?” I asked, finally verbalizing what had been bugging me all week.
“The not-so-simple answer? Yes.”
Oh, man, I thought. Now I really have to find out what the hell is going on.
I couldn’t stop thinking about how extreme this physical presentation was. If what was in the “well” in Bayview was adversity, Diego had experienced a high dose of it, the equivalent of drinking a jug of cholera-infested water. If I could figure out what was going on with Diego on a biochemical level, maybe I would learn what was going on with all of my patients. Maybe it was even the key to what was going on in the community at large. I had four major questions to answer: Was the exposure (trauma/adversity) at the bottom of the well making people sick? How? Could I prove it? And most important, what could I do about it medically?
One immediate problem with getting to the bottom of this larger connection between adversity and ill health was that at times, there was an overwhelming number of factors to consider—my patients’ different upbringings, their genetic histories, their environmental exposures, and, of course, their individual traumas. I already knew it wasn’t going to be as simple as identifying a shared water source and a single type of bacterium. With Diego, an incident of abuse had acted as a catalyst that (presumably) set off a biochemical chain reaction resulting in growth arrest. But all kinds of wild things had to go on, and keep going on, hormonally and cellularly, for the body to react in such an extreme way. Figuring this out would take some doing. I saw the next months of my life flash in front of me; it was nothing but PubMed, granola bars, and eye strain.
That day at the clinic, I stayed well into the evening, combing through patient charts for patterns I might have missed. Eventually I got up and began to pace. All the patients and staff had gone home, so I was free to wander without distraction. I meandered through the waiting room, stopping to smile at the mini-furniture and the primary-color footprints stenciled on the rug. These things reminded me yet again that my patients were normal kids, regardless of what they had been through or would go through.
When I was first working for CPMC in Laurel Heights, my favorite part of the job was examining newborns. Years later, I did identical exams on the newborns of Bayview, and I found that their little hearts sounded the same under my stethoscope. When I put a gloved finger in an infant’s mouth, the same adorable suckling reflex kicked in. They all had the same soft spots on the tops of their heads where the skull bones hadn’t quite closed yet. These babies came into the world no different than the ones born in Laurel Heights, yet as I did newborn exams in Bayview, I knew that these human beings’ lives would, according to the statistics, be twelve years shorter than the lives of the children in Laurel Heights. Not because their hearts were made differently or because their kidneys didn’t function the same way, but because somewhere in the future, something in their bodies would change—something that would alter the trajectory of their health for the rest of their lives. At the beginning, they are equal, these beautiful bundles of potential, and knowing that they won’t always be is enough to break your heart.
I walked into the exam room just before leaving for home, flipped on the light, and looked at the animals stenciled on the wall—lions, giraffes, horses, and, strangely, a single, solitary frog. My gaze lingered there. Maybe it was that the frog was oddly solo, or maybe it was just the brain’s mysterious way of connecting the dots, but suddenly I remembered the Hayes lab at the University of California, Berkeley. When I was twenty years old I logged some serious hours there, and frogs were a big part of it. The Hayes lab was an amphibian research lab where the inimitable Dr. Tyrone Hayes was studying the effects of corticosteroids (stress hormones) on tadpoles at different stages of their development. The ghosts of research past flooded my brain, intersecting with the problem I’d been fighting all day: Everything I’d learned in my training told me that adversity was a social determinant of poor health outcomes, but what was never examined was how it affected physiology or biological mechanisms. There wasn’t any research that I could fall back on to help me understand how my patients’ traumatic experiences could be affecting their biology and their health.
Or maybe there was.
Maybe to figure out what was going on with Diego and all the little tadpoles in Bayview, I had to look for clues in more cold-blooded circles.