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Roadmap for Resilience: The California Surgeon General’s Report on Adverse Childhood Experiences, Toxic Stress, and Health

Bhushan D, Kotz K, McCall J, Wirtz S, Gilgoff R, Dube SR, Powers C, Olson-Morgan J, Galeste M, Patterson K, Harris L, Mills A, Bethell C, Burke Harris N, Office of the California Surgeon General – 2020

In establishing the Office of the California Surgeon General, it was important to me to begin by visiting communities and listening. I wanted to more fully understand the complexities of our most pressing challenges, as well as the bright spots of innovation and the creative problem-solving that exist all over our great state. In the past year and a half, I have had the privilege to visit the places where Californians live, learn, work, play, and pray, as well as the opportunity to see up close what residents throughout our state are experiencing. Each community shared their unique challenges—such as homelessness, substance dependence, mental illness, and difficulty accessing healthcare—and successful approaches or proposed solutions. Over and over, I heard that communities identified trauma as a root cause of many of the challenges they are facing. Californians clearly recognize what the science has been revealing over the past several decades: that adversity, especially in the early years of life, can dramatically curtail health and life opportunities. In California, more than six out of 10 of us have experienced at least one Adverse Childhood Experience (ACE), such as having a caregiver with mental illness or witnessing domestic violence, and one in six of us have experienced four or more ACEs. The consequences for individuals and communities across our state are significant. An individual with four or more ACEs has a 70% higher risk of kidney disease, more than double the risk of heart disease, and triple the risk of chronic lung disease as someone without ACEs. He or she is also 4.7 times as likely to experience depression and 10.2 times as likely to become dependent on substances; experiencing any ACEs increases the risk of homelessness by two to four times. We now have the science to understand that the toxic stress response is a key biological mechanism by which ACEs lead to these downstream consequences. ACEs and toxic stress represent a public health crisis in California and across our nation. The good news is that ACEs are not destiny! Every day, we are learning more about how to effectively interrupt the progression from early adversity to disease and early death. These lessons are being applied to policy and practice in our clinics and hospitals, schools, workplaces, childcare centers, courtrooms, and elsewhere throughout our communities. Roadmap for Resilience iii What has surprised me most, and what fuels my optimism, is the broad range of steps already being taken by passionate healthcare providers, community leaders, government officials, advocates, educators, and others to advance innovative solutions. We have an army of people who have rolled up their sleeves and are willing and ready, or already hard at work on these issues. In my role as California Surgeon General, I am committed to empowering these medical and social innovations, and marshalling the energy and insights of our healthcare and community leaders to catalyze breakthrough solutions. This work could not be more timely. Today, in the midst of a global pandemic, record setting wildfires, and historic civil unrest, many communities across California are experiencing greater adversities than ever before. The extraordinary disruptions and hardships brought on by these circumstances have impacted everyone, but particularly our most vulnerable neighbors. There has never been a more urgent time for trauma informed care everywhere. This report is intended to act as a blueprint for primary, secondary, and tertiary prevention—that is, prevention, early detection, and cross-sector coordinated interventions to address ACEs and toxic stress in a systematic way. None of these strategies is sufficient alone, and each extends the reach of the others. As California Surgeon General, I have set a bold goal to cut ACEs and toxic stress in half in one generation. I believe that we can get there with shared vision, shared understanding, and clear roles and responsibilities to help align cross-sector efforts. This report is grounded in the most up-to-date science, and highlights evidence-based and promising practices that can be applied at the federal, state, county, and community levels within and across sectors. Together, we can break the intergenerational cycle of adversity. Most importantly, as we move forward in this work, I urge everyone to start by putting their own “oxygen masks” on. This is long and difficult work, and we need you in this fight. Self-care is not selfish—it is an essential first step in an individual, family, or community’s journey to healing. Please join me in enacting the solutions laid out in these pages to realize a more just and equitable reality where we can truly prevent and heal from childhood adversity. With gratitude, Nadine Burke Harris, MD, MPH California Surgeon General