THE BEAUTY AND THE challenge of working in a clinic like mine was that, regardless of your own needs (sleep!) or desires (lunch!), there was an undertow of urgency that always pulled you back to your patients. After work I sometimes had the luxury of time to investigate the connection between adversity and health, but when I was in the clinic, I had a stack of charts and a waiting room full of sick kids. With Diego in particular, I felt that familiar tug. While I had written him prescriptions for an inhaler and eczema medication, I still needed to tackle the growth arrest. I enlisted the help of Dr. Bhatia once again. I wondered if a course of hormonal therapy might be necessary, but she reminded me that Diego’s labs hadn’t shown hormonal imbalances, or at least none we could measure. Her experience was that, in cases such as these, medication likely wouldn’t help. To my surprise, she said the most effective type of treatment for Diego was talk therapy.
Luckily, I already had someone to turn to. The Bayview Child Health Center had received a small grant for patient-support services, and when it came to figuring out what to do with it, I knew just who to ask—the community itself. I understood from my training that building relationships in underserved communities is important for improving health outcomes, which is why I made it a part of my work to help schools and churches plan health fairs, nutrition programs, and asthma-prevention classes. Folks got used to seeing my face in the neighborhood. Many well-meaning people had come and gone in Bayview, leaving a multitude of unfulfilled promises in their wake, but the community was beginning to believe me when I said I was committed to improving the health of their children.
When the grant money for patient support arrived, the answer regarding how to spend it was clear: mental-health services. Though at the time it was pretty unusual for a pediatric office to have a therapist on staff, my colleagues and I knew enough to give the members of the community what they said they needed, not what we thought they needed.
But I was nervous about finding the right person to fill the therapist position. We were a nonprofit health center in the middle of Bayview Hunters Point with minimal staff and budget and plenty of intense, unpaid overtime to go around. While that kind of work might have been my idea of a dream job, I wasn’t crazy enough to think it was everybody’s. When Dr. Whitney Clarke walked into my office for an interview, my hopes fell. Even though I certainly knew enough not to judge someone by outward appearances, I still thought, There is no way this is the guy.
It would be an understatement to say that someone who looks like Dr. Clarke is not the first image to come to mind when you think of a therapist working in a community like Bayview. He’s male, he’s white, and he’s a dead ringer for Chris Pine (the actor who plays a young Captain Kirk in the new Star Trek films). Basically, he’s a walking Abercrombie and Fitch ad. Which to me meant that patients would have trouble trusting him and connecting with him—something of a problem for a therapist in a marginalized, high-needs community. But after we talked for a long time, my initial skepticism started to thaw and I saw something in him that I had a hunch my patients would respond to.
Most of my patients, predictably, pushed back when I referred them to Dr. Clarke. “I’m not taking my child to a white therapist” was a common and understandable refrain. These families were in a vulnerable place, and many had experienced the kind of institutionalized racism that breeds a deep mistrust of outsiders and a reflexive defensiveness. Luckily, by then I had built a strong enough relationship with the community that when I vouched for Dr. Clarke and said I thought he could make a huge difference for their kids, they trusted me. It was never long before they saw him for who he was: a fiercely caring, easy-to-talk-to skilled practitioner who quickly became a sort of haven for them. I always loved it when these patients’ families saw me again months later glowing with a kind of pride about him. Soon, they were vouching for him too.
After talking with Dr. Bhatia about Diego, I brought Dr. Clarke up to speed and asked what type of therapy plan we should recommend for him. Soon we had connected Rosa with a Spanish-speaking therapist who was experienced in trauma-focused cognitive behavioral therapy (TF-CBT for short), a clinical protocol designed to address the impact of trauma on a child’s development by working with both parent and child.
With that knocked off my endless to-do list, I felt better, but although Diego was now on the best treatment plan we could devise, I was still frustrated. I was seeing more and more clearly in my patients a connection between adversity and poor health, but I felt totally unprepared to deal with it. While I was grateful for Dr. Bhatia’s guidance regarding Diego’s growth, there were many other times when I had no one to call. The previous decade of experiences had led me to trust that what I was seeing was real, but if it was true, why hadn’t I learned how to treat it in medical school or residency? Where were the clinical protocols? Where were committees’ recommendations to doctors about what to do about this?
Whitney Clarke was often a sounding board for my frustration. Time and again we talked about my hypothesis that adversity was at the root of both the mental-health symptoms he was treating and my most vexing medical cases. Despite his lack of background in endocrinology, it made perfect sense to him. He even reminded me of a few other extreme cases that we’d come up against that fit the Diego stress-symptom mold.
A couple of months later, Dr. Clarke came to my office and handed me a research paper with a big smile on his face.
“Have you seen this?” he asked.
It was a 1998 article in the American Journal of Preventative Medicine: “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: the Adverse Childhood Experiences (ACE) Study,” by Dr. Vincent Felitti, Dr. Robert Anda, and colleagues.
“No,” I said, sensing by his tone that this was something important.
“You might want to take a break from charting,” he said.
“Is this what I think it is?”
“Just take a look and then come talk to me,” he said.
Before he could even shut the door I was halfway through the abstract. I was only partway through the first page when I experienced a jolt of recognition.
Here it was.
The final puzzle piece that pulled all the others into place.
Everything I had experienced in the past ten years, all of those questions and observations that I couldn’t quite put together, suddenly had a linchpin. With my heart knocking in my chest, I started to read aloud the particularly mind-blowing parts of the study, occasionally stopping to whisper-shout in Jamaican patois. The first thing that struck me about Felitti and Anda’s research was how incredibly robust it was: they reported data from 17,421 people, which was a large enough number to provide the validation I’d never thought I’d find.
When I finished reading the study, my excitement hadn’t diminished. I felt like Neo at the end of the movie The Matrix when suddenly the world was dripping with green numbers. Not only was I seeing the full reality of what was all around me, but I understood it. According to the ACE Study, I wasn’t the only one making connections between the stress of childhood adversity and bad health outcomes. This piece of the puzzle, the final piece of code in the Matrix, was just what I needed to make sense of what was going on with my patients and, more important, to treat them. At the time, I knew that this moment, this understanding, was going to profoundly change my practice, but I had no idea how much it would change my life.
It was 1985 at the Kaiser obesity clinic in San Diego, and Dr. Vincent Felitti was interviewing his first patient of the day. If you were to stand behind Dr. Felitti in line for soup at the hospital cafeteria or glide past him in the hallway, you would probably be struck by his bearing. Stately. Composed. These are the words you might use. Every bit the poised intellectual with a full head of thick, white hair, he looked ready to host the news hour on public television or calmly moderate a debate between acrimonious politicians. He spoke with confidence and authority and was extremely articulate. Which was why when he told me this story, I was blown away to discover that his biggest medical breakthrough had happened because of a verbal slip.
Donna was a fifty-three-year-old woman with debilitating diabetes and a significant weight problem. In a new weight-loss program, she had successfully lost upwards of one hundred pounds two years before, but in the past six months, she’d put it all back on. Felitti felt a conflicting sense of frustration and responsibility. The truth was he didn’t really know why Donna had gone off the rails. She had been doing so well and then, after all her hard work and success, she was right back where she started.
Felitti was determined to get to the bottom of it.
He rattled off a list of his usual preliminary questions: How much did you weigh when you were born? How much did you weigh when you started first grade? How much did you weigh when you entered high school? How old were you when you first became sexually active?
But this time, he misspoke.
Instead of asking, “How old were you when you first became sexually active?” he asked, “How much did you weigh when you first became sexually active?”
“Forty pounds,” said Donna.
Her answer stopped him short. Wait a minute, forty pounds?
He was pretty sure he’d heard her wrong, and for a minute he didn’t say anything, but then something made him ask the question again the same way. Maybe she had meant one hundred and forty pounds.
“Sorry, Donna, how much did you weigh when you first became sexually active?”
She went quiet.
He waited for her to speak, sensing there was something here. Working with patients for over two decades had taught him that on the other side of a pregnant pause was usually the diagnostic gold.
“I was forty pounds,” Donna said, looking down.
Felitti waited, stunned.
“It was when I was four years old, with my father,” she said.
Felitti told me that in the moment, he was shocked, but he struggled not to show his emotions (I knew the feeling all too well). In twenty-three years of working with patients, he had never heard someone tell a story of sexual abuse during a checkup. Nowadays, that would be hard to believe. I wondered if it was because he had never asked or because it was the eighties, when stories of abuse were even more buried than they are today. When I asked him about it, Felitti said he thought he’d probably never asked; he was a doctor, after all, not a therapist.
Weeks after speaking to Donna, Felitti interviewed another noncompliant patient who was part of the same weight-loss program. Patty had actually started out as a model patient; in a jaw-dropping fifty-one weeks, she had gone from 408 to 132 pounds. Patty and Donna weren’t alone. Many other patients were also experiencing great results, some losing up to three hundred pounds in one year on the regimen. Felitti was excited by the outcomes, but the high dropout rate was puzzling. If it had been patients who were still early in the process, the attrition would have been understandable. After all, the fasting regimen they committed to was challenging. But the strange part was that the dropout rate was highest among the most successful patients—the very ones who had stuck with it the longest and seen the best results. Just as they were reaching their ideal weights, when they should have been celebrating their hard-won goals, these successful patients suddenly disappeared. They would drop out of the program permanently or leave and come back months later, having regained a majority of the weight they had lost. Felitti and his colleagues were left scratching their heads. They had found what seemed to be a solution for a notoriously intractable problem, yet it was proving unsustainable for no discernible reason.
Felitti was meeting with Patty to try to understand what was going on. He could tell she was on the verge of dropping out of the program because in the past three weeks she had regained thirty-seven pounds. She was going the wrong way, fast. He hoped he could get her back on track before it was too late.
He performed a physical examination on Patty to see if he could determine what was behind the sudden weight gain. Was her heart failing, causing her to retain large amounts of fluid? As far as Dr. Felitti could tell, she wasn’t exhibiting the bloating or puffiness that indicated fluid retention associated with heart failure. Was her thyroid out of whack? He took a closer look at her hair, skin, and nails but didn’t observe any dryness or thinning, and her thyroid was a normal size. There didn’t seem to be any physical signs of a metabolic problem.
After checking everything off the list, Felitti sat down with her for a talk.
“Patty, what do you think is going on here?”
“You mean the weight?”
“Yes.”
Her smile dimmed and she looked down at her hands.
“I think I’m sleep-eating,” she said sheepishly.
“What do you mean?” Felitti asked.
“When I was a kid, I used to be a sleepwalker. I haven’t done that for years, but I live alone and when I go to bed at night everything is clean and put away in the kitchen. Now, when I wake up in the morning, the pots and dishes are dirty, the boxes and cans are open. Somebody has obviously been cooking and eating, but I can’t remember any of it. Since I’m the only person there and I’m putting on weight, I guess it’s the only explanation.”
Felitti nodded. It seemed a little wacky, possibly even a sign of some sort of psychopathology. Ordinarily, he’d refer her to mental-health services and focus his attention on addressing her physical health, but something stopped him. His recent conversation with Donna made him realize there were things that might be affecting his patients’ success that he wasn’t getting at with his usual questioning. He decided to follow this thread even though it seemed outside of his area of expertise.
“Patty, that you’re sleep-eating explains the weight gain, but why are you doing it now?”
“I don’t know.”
“But why didn’t this happen three years ago, or three months ago?”
“I don’t know.”
Felitti tried again. His work in infectious disease and epidemiology wouldn’t let him stop with the surface explanation. There was usually a trigger event. Cholera didn’t affect so many people in the Soho neighborhood of London because of bad luck; there was something tying together all the people who got sick, and that something was a contaminated well.
Felitti doubted that Patty had started sleep-eating for no reason.
“Think hard, Patty. What’s been happening in your life? Why would you start sleep-eating now?”
She was quiet for a moment.
“Well, I don’t know if it’s related, but there’s this man at work,” she said, looking down again.
Felitti waited, and eventually Patty went on to explain that in her job as a nurse at a convalescent home, she’d been in charge of a new patient who kept hitting on her. He was much older and married, and he had remarked on how good she looked now that she’d lost all that weight. He’d been propositioning her ever since. At first, Felitti was perplexed. It didn’t totally line up that this rather mild harassment (it was the eighties, after all) was enough to set her off in such an extreme way, but as he probed further, things became a lot more clear. Patty had a lengthy history of incest at the hands of her grandfather, starting when she was ten years old. This was also when she had begun to struggle with her weight.
After Patty left that day, Dr. Felitti realized that he couldn’t ignore the similarities between her and Donna. Maybe it had just been a coincidence, but what stuck with him was the timing. Both patients had begun to gain weight as children immediately subsequent to incidents of abuse. Fast-forward a few decades; Patty’s sudden weight gain coincided with being hit on by her patient. Felitti wondered if she might be subconsciously protecting herself from what must have seemed like a recurring trauma by gaining weight. What if he had been looking at this all wrong? He, as a doctor, had perceived a patient’s weight to be the problem. What if it was actually a solution? What if his patient’s weight was a psychological and emotional barrier, something protecting her from harm? That would go a long way toward explaining why his most successful patients, the ones who had peeled off that protective layer, were so desperate to put it back on.
Felitti suspected that he might have glimpsed a hidden relationship between histories of abuse and obesity. To get a clearer picture of that potential relationship, when he conducted his normal checkups and patient interviews for the obesity program, he now began asking people if they had a history of childhood sexual abuse. To his shock, it seemed as if every other patient acknowledged such a history. At first he thought there was no way this could be true. Wouldn’t he have learned about this correlation in medical school? However, after 186 patients, he was becoming convinced. But in order to make sure there wasn’t something idiosyncratic about his group of patients or about the way he asked the questions, he enlisted five colleagues to screen their next hundred weight patients for a history of abuse. When they turned up the same results, Felitti knew they had uncovered something big.
Dr. Felitti’s initial insight about the link between childhood adversity and health outcomes led to the landmark ACE Study. This was a prime example of doctors thinking like detectives, following a hunch and then putting it through its scientific paces. Beginning with just two patients, this research would eventually become both the foundation and the inspiration for ongoing work giving medical professionals critical insight into the lives of so many others.
After the initial detective work within his own department, Felitti started trying to spread the word. In 1990 he presented his findings at a national obesity meeting in Atlanta and was roundly criticized by his peers. One physician in the audience insisted that patients’ stories of abuse were fabrications meant to provide cover for their failed lives. Felitti reported that the man got a round of applause.
There was at least one person at the conference who didn’t think Dr. Felitti had been hoodwinked by his patients. An epidemiologist from the Centers for Disease Control and Prevention (CDC), David Williamson was seated next to Felitti at a dinner for the speakers later that night. The senior scientist told Felitti that if what he was claiming—that there was a connection between childhood abuse and obesity—was true, it could be enormously important. But he pointed out that no one was going to believe evidence based on a mere 286 cases. What Felitti needed was a large-scale, epidemiologically sound study with thousands of people who came from a wide cross-section of the population, not just a subgroup in an obesity program.
In the weeks following their meeting, Williamson introduced Felitti to a physician epidemiologist at the CDC, Robert Anda. Anda had spent years at the CDC researching the link between behavioral health and cardiovascular disease. For the next two years Anda and Felitti would review the existing literature on the connection between abuse and obesity and figure out the best way to create a meaningful study. Their aim was to identify two things: (1) the relationship between exposure to abuse and/or household dysfunction in childhood and adult health-risk behavior (alcoholism, smoking, severe obesity), and (2) the relationship between exposure to abuse and/or household dysfunction in childhood and disease. To do that, they needed comprehensive medical evaluations and health data from a large number of adults.
Fortunately, part of the data they needed was already being collected every day at Kaiser Permanente in San Diego, where over 45,000 adults a year were getting comprehensive medical evaluations in the health appraisal center. The medical evaluations amassed by Kaiser would be a treasure trove of important data for Felitti and Anda because they contained demographic information, previous diagnoses, family history, and current conditions or diseases each patient was dealing with. After nine months of battling and finally gaining approval from the oversight committees for their ACE Study protocol, Felitti and Anda were ready to go. Between 1995 and 1997, they asked 26,000 Kaiser members if they would help improve understanding of how childhood experiences affected health, and 17,421 of those Kaiser health-plan members agreed to participate. A week after the first two visits for this process, Felitti and Anda sent each patient a questionnaire asking about childhood abuse and exposure to household dysfunction as well as about current health-risk factors, like smoking, drug abuse, and exposure to sexually transmitted diseases.
The questionnaire collected crucial information about what Felitti and Anda termed “adverse childhood experiences,” or ACEs. Based on the prevalence of adversities they had seen in the obesity program, Felitti and Anda sorted their definitions of abuse, neglect, and household dysfunction into ten specific categories of ACEs. Their goal was to determine each patient’s level of exposure by asking if he or she had experienced any of the ten categories before the age of eighteen.
Emotional abuse (recurrent)
Physical abuse (recurrent)
Sexual abuse (contact)
Physical neglect
Emotional neglect
Substance abuse in the household (e.g., living with an alcoholic or a person with a substance-abuse problem)
Mental illness in the household (e.g., living with someone who suffered from depression or mental illness or who had attempted suicide)
Mother treated violently
Divorce or parental separation
Criminal behavior in household (e.g., a household member going to prison)
Each category of abuse, neglect, or dysfunction experienced counted as one point. Because there were ten categories, the highest possible ACE score was ten.
Using the data from the medical evaluations and the questionnaires, Felitti and Anda correlated the ACE scores with health-risk behaviors and health outcomes.
First, they discovered that ACEs were astonishingly common—67 percent of the population had at least one category of ACE and 12.6 percent had four or more categories of ACEs.
Second, they found a dose-response relationship between ACEs and poor health outcomes, meaning that the higher a person’s ACE score, the greater the risk to his or her health. For instance, a person with four or more ACEs was twice as likely to develop heart disease and cancer and three and a half times as likely to develop chronic obstructive pulmonary disease (COPD) as a person with zero ACEs.
Given what I’d seen in my patients and in the community, I knew in my bones that this study was dead-on. It was powerful evidence of the connection that I had seen clinically but had never seen substantiated in the literature. After reading the ACE Study, I was able to answer the question of whether there was a medical connection between the stress of childhood abuse and neglect and the bodily changes and damage that could last a lifetime. It seemed clear now that there was a dangerous exposure in the well at Bayview Hunters Point. It wasn’t lead. It wasn’t toxic waste. It wasn’t even poverty, per se. It was childhood adversity. And it was making people sick.
One of the most revealing parts of the ACE Study was not what it investigated but who it investigated. Many people might look at Bayview Hunters Point and see the rates of poverty and violence and the lack of health care and say, “Of course those people are sicker; that makes sense.” After all, that’s what I learned in public-health school. Poverty and lack of adequate health care are what really drives poor health outcomes, right?
This is where the ACE Study comes in and shakes things up, showing us that the dominant view is missing something big. Because where was the ACE Study conducted?
Bayview? Harlem? South-Central Los Angeles?
Nope.
Solidly middle-class San Diego.
The original ACE Study was done in a population that was 70 percent Caucasian and 70 percent college-educated. The study’s participants, as patients of Kaiser, also had great health care. Over and over again, further studies about ACEs have validated the original findings. The body of research sparked by the ACE Study makes it clear that adverse childhood experiences in and of themselves are a risk factor for many of the most common and serious diseases in the United States (and worldwide), regardless of income or race or access to care.
The ACE Study is powerful for a lot of reasons, but a big one is that its focus goes beyond behavioral or mental-health outcomes. The research wasn’t conducted by a psychologist; it was conducted by two internal medicine doctors. Most people intuitively understand that there’s a connection between trauma in childhood and risky behavior, like drinking too much, eating poorly, and smoking, in adulthood (more on that later). But what most people don’t recognize is that there is a connection between early life adversity and well-known killers like heart disease and cancer. Every day in the clinic I saw the way my patients’ exposure to ACEs was taking a toll on their bodies. They may have been too young for heart disease, but I could certainly see the early signs in their high rates of obesity and asthma.
Along with my excitement at finding the ACE Study’s demonstration of links between adversity and disease came a wave of indignation: Why was I only hearing about this now? This study was clearly a game-changer, yet I hadn’t learned about it in med school, public-health school, or even residency. Felitti and Anda published their initial ACE findings in 1998, and I didn’t read them until 2008. Ten years! And still this important science hadn’t been translated into clinical tools I could use to improve my patients’ health. How could that be possible?
When I talked to Felitti years later, he mentioned attacks on parts of the paper by various colleagues. While Felitti and Anda successfully refuted the criticisms, the work never seemed to gain traction. In fact, it almost seemed to disappear, which is kind of crazy when you think about what the study revealed. Dr. Anda’s colleagues at the Centers for Disease Control were agog, telling him that the magnitude of the increased likelihood of disease was the sort seen only a couple of times in a researcher’s career. A critical piece of their findings was the dose-response relationship; for example, the more cigarettes you smoke and the more years you smoke them, the higher your odds of developing lung cancer. The ACE Study strongly establishes a dose-response relationship, which is an important step toward demonstrating causality. A person with an ACE score of seven or more has triple the lifetime odds of getting lung cancer and three and a half times the odds of having ischemic heart disease, the number one killer in the United States. If a large study like Felitti and Anda’s came out tomorrow saying that exposure to cottage cheese tripled your lifetime chances of cancer, the Internet would break and the dairy lobby would hire a crisis-management firm.
So what gives? Why hadn’t I heard of this study before? Why wasn’t I listening to stories about it on NPR and watching Dr. Felitti be interviewed by Oprah? I can see now that there were at least three reasons.
The first has to do with a misconception concerning the ACE Study itself, the belief of some that the increased risks had everything to do with behavior. As I said earlier, many people assume they understand the adversity-health connection. The popular thinking goes that if you live in poverty or have a rough childhood, you inevitably cope by drinking and smoking and doing other risky things that damage your health. But if you’re smart and strong, you rise above what you were born and raised with and leave the bad things behind. At first, this construct seems to make sense, but remember, at one point it made perfect sense that the Earth was flat.
Fortunately, some smart scientists decided to test the behavioral assumption. They looked at the association between ACEs and heart and liver disease and did some very complicated analyses to assess how much of the disease was due to the effects of health-damaging behaviors like smoking, drinking, physical inactivity, and obesity. It turned out that “bad behavior” accounted for only about 50 percent of increased likelihood for disease. In a way that’s good news, because it means that if a person is exposed to ACEs and he is careful to avoid smoking, physical inactivity, and other health-damaging behaviors, he can protect himself from about 50 percent of the health risk. But it also means that even if he doesn’t engage in any health-damaging behaviors, he’s still more likely to develop heart or liver disease.
Felitti’s patient Patty is a good example. She was severely obese and a self-described sleep-eater, so obviously her behaviors caused her obesity, which caused her later health problems, right? Not so fast. After dropping out of Dr. Felitti’s program initially, she returned later, asking for more help with her weight problem. Over the years she would lose the weight and put it back on over and over again, even after bariatric surgery. Sadly, Patty died at the age of forty-two of pulmonary fibrosis, an autoimmune condition that damages the lung tissue and makes breathing difficult and, eventually, impossible. But obesity is not the cause of pulmonary fibrosis. Patty didn’t smoke and she had never been exposed to any known pulmonary toxins like asbestos. Having an ACE score of two or more doubles someone’s likelihood of developing an autoimmune disease. Patty’s ACEs were likely her biggest risk factor, yet neither she nor her doctors knew it.
In the United States, the culture puts a lot of stock in personal responsibility. The lifestyle choices you make do have a huge impact on your health; so-called bad behavior does result in increased risks to your health, and there’s no disputing that. But the ACE Study shows us, yet again, that it’s not the whole story.
The second reason I hadn’t heard of Felitti and Anda’s work in medical school, and maybe the most potent, is that this is scary, emotional stuff. It’s one thing to take a cold, calculating look at your cottage-cheese consumption over the past decade, but it’s another to revisit trauma and abuse. I bet everyone reading this book can think of someone who grew up with a family member who suffered from mental illness or who had a parent who drank too much, or who was emotionally abusive, or who believed that sparing the rod spoiled the child. In any group you might find yourself in—a classroom, a professional conference, a wedding party, the U.S. Congress—if everyone’s ACE score was suddenly revealed, it would show pretty clearly that this is an issue that touches many of us. But most of us don’t like to think about the sad, upsetting things that have happened in the past. It’s possible that we marginalize the impact of trauma on health because it does apply to us. It’s hard, after all, to accept that there might be biological implications that persist whether people are sinners or saints. Maybe it’s just easier to see it in other zip codes.
The last reason why the ACE Study didn’t catch fire in the medical and scientific communities in 1998 can be best explained as scientific gaps. The study showed that adversity was bad for your health, but although Felitti and Anda had exposed the what, they were unable at the time to answer the how.
Lucky for me, there had been ten years of intervening research that had slowly but surely filled in those scientific gaps.
Now what I needed to do was return to the Hayes lab and Sarah P. and dig deeper into that how. In my gut, I had a strong sense of what puzzle pieces fit in the ACE Study’s scientific gaps. Identifying and demonstrating that the stress-response system was the biological mechanism behind adversity’s role in health was going to be the fun part. I’d have to jump back into those journals and hit up some medical conferences, but now I had the ACE Study to guide me. I could use its language in my searches, interrogate its authors for clues, and even start collecting my own ACE data at the clinic. The realization that this was bigger than my patients, bigger than Bayview, made my heart pound. Adversity’s detrimental impact on health had all the hallmarks of a public-health crisis hidden in plain sight.
Before I met Diego or even knew about ACEs, I had hope for Bayview. I knew problems there were amplified but that their solutions would be too. On our first day at the clinic, I told my staff that if we could successfully treat people here, we could treat people anywhere.