In the mid-'90s, the CDC and Kaiser Permanente discovered an exposure that dramatically increased the risk for seven out of 10 of the leading causes of death in the United States. In high doses, it affects brain development, the immune system, hormonal systems, and even the way our DNA is read and transcribed. Folks who are exposed in very high doses have triple the lifetime risk of heart disease and lung cancer and a 20-year difference in life expectancy. And yet, doctors today are not trained in routine screening or treatment. Now, the exposure I'm talking about is not a pesticide or a packaging chemical. It's childhood trauma.
Sredinom devedesetih, Centar za kontrolu bolesti (CKB) i "Kaizer Permanente" su otkrili izlaganje koje drastično povećava rizik za sedam od deset vodećih uzroka smrti u Sjedinjenim Državama. U velikim dozama, utiče na razvoj mozga, imuni sistem, hormonalne sisteme, čak i na način na koji se DNK čita i preslikava. Ljudi koji su izloženi u velikim dozama imaju trostruki rizik da obole od bolesti srca i raka pluća i razliku od 20 godina očekivane dužine života. A ipak, doktori danas nisu obučeni za rutinsku proveru ili tretman. Izloženost o kojoj govorim nije pesticid ili hemikalija. To je trauma u detinjstvu.
Okay. What kind of trauma am I talking about here? I'm not talking about failing a test or losing a basketball game. I am talking about threats that are so severe or pervasive that they literally get under our skin and change our physiology: things like abuse or neglect, or growing up with a parent who struggles with mental illness or substance dependence.
Okej. O kakvoj traumi govorim? Ne pričam o padanju na ispitu niti izgubljenoj utakmici košarke. Govorim o opasnostima koje su toliko ozbiljne ili prožimajuće da nam se bukvalno uvuku pod kožu i menjaju našu fiziologiju, kao što su zlostavljanje i zanemarivanje, ili odrastanje sa roditeljem koji se bori sa mentalnom bolešću ili bolešću zavisnosti.
Now, for a long time, I viewed these things in the way I was trained to view them, either as a social problem -- refer to social services -- or as a mental health problem -- refer to mental health services. And then something happened to make me rethink my entire approach. When I finished my residency, I wanted to go someplace where I felt really needed, someplace where I could make a difference. So I came to work for California Pacific Medical Center, one of the best private hospitals in Northern California, and together, we opened a clinic in Bayview-Hunters Point, one of the poorest, most underserved neighborhoods in San Francisco. Now, prior to that point, there had been only one pediatrician in all of Bayview to serve more than 10,000 children, so we hung a shingle, and we were able to provide top-quality care regardless of ability to pay. It was so cool. We targeted the typical health disparities: access to care, immunization rates, asthma hospitalization rates, and we hit all of our numbers. We felt very proud of ourselves.
Dugo sam ove stvari sagledavala onako kako sam bila obučena da ih sagledavam, ili kao društveni problem - koji se tiče socijalnih službi - ili kao problem mentalnog zdravlja - upućuje se na službe za mentalno zdravlje. A onda se dogodilo nešto zbog čega sam preispitala svoj pristup. Kada sam završila specijalizaciju, želela sam da odem negde gde sam osećala da sam zaista potrebna, negde gde mogu da ostvarim promenu. Tako sam počela da radim za medicinski centar Kalifornija Pacifik jednu od najboljih privatnih bolnica u severnoj Kaliforniji, i zajedno smo otvorili kliniku u Bejvju-Hanters Pointu, jednom od najsiromašnijih krajeva u San Francisku. Pre toga, postojao je samo jedan pedijatar u celome Bejvjuu koji je lečio više od 10 000 dece, pa smo mi započeli ovaj posao i mogli smo da pružimo vrhunsku negu bez obzira na nečiju mogućnost da plati. Bilo je baš kul. Bili smo usmereni na tipične zdravstvene nejednakosti: pristup nezi, stope vakcinisanosti, stope hospitalizacije zbog astme, i postigli smo sve naše ciljeve. Bili smo vrlo ponosni na sebe.
But then I started noticing a disturbing trend. A lot of kids were being referred to me for ADHD, or Attention Deficit Hyperactivity Disorder, but when I actually did a thorough history and physical, what I found was that for most of my patients, I couldn't make a diagnosis of ADHD. Most of the kids I was seeing had experienced such severe trauma that it felt like something else was going on. Somehow I was missing something important.
Ali zatim sam počela da primećujem uznemirujuću tendenciju. Mnogo dece mi je bilo upućeno zbog ADHD-a, poremećaja pažnje sa hiperaktivnošću, ali kada sam pregledala njihove kartone i obavila pregled, otkrila sam da većini mojih pacijenata nisam mogla da dijagnostikujem ADHD. Većina dece koju sam primila doživela je tako ozbiljnu traumu, da se sticao utisak da se tu nešto drugo zbiva. Nekako mi je promicalo nešto važno.
Now, before I did my residency, I did a master's degree in public health, and one of the things that they teach you in public health school is that if you're a doctor and you see 100 kids that all drink from the same well, and 98 of them develop diarrhea, you can go ahead and write that prescription for dose after dose after dose of antibiotics, or you can walk over and say, "What the hell is in this well?" So I began reading everything that I could get my hands on about how exposure to adversity affects the developing brains and bodies of children.
Pre specijalizacije, stekla sam diplomu mastera javnog zdravlja i jedna od stvari kojima uče u školi za javno zdravlje je da, ako ste doktor i vidite da stotinu dece pije sa istog bunara, i 98 dobije proliv, možete da im prepišete antibiotike jednu dozu za drugom, ili možete da priđete i pitate: "Šta je to u ovom bunaru?" Tako sam počela da čitam sve čega sam dokopala o tome kako izloženost nepovoljnim uslovima utiče na mozak u razvoju i tela dece.
And then one day, my colleague walked into my office, and he said, "Dr. Burke, have you seen this?" In his hand was a copy of a research study called the Adverse Childhood Experiences Study. That day changed my clinical practice and ultimately my career.
Onda jednog dana, kolega je ušao u moju kancelariju, i rekao je: "Doktorka Burk, jeste li videli ovo?" U ruci je imao kopiju istraživanja nazvanog Studija nepovoljnih iskustava u detinjstvu. Taj dan je promenio moju kliničku praksu i naposletku i moju karijeru.
The Adverse Childhood Experiences Study is something that everybody needs to know about. It was done by Dr. Vince Felitti at Kaiser and Dr. Bob Anda at the CDC, and together, they asked 17,500 adults about their history of exposure to what they called "adverse childhood experiences," or ACEs. Those include physical, emotional, or sexual abuse; physical or emotional neglect; parental mental illness, substance dependence, incarceration; parental separation or divorce; or domestic violence. For every yes, you would get a point on your ACE score. And then what they did was they correlated these ACE scores against health outcomes. What they found was striking. Two things: Number one, ACEs are incredibly common. Sixty-seven percent of the population had at least one ACE, and 12.6 percent, one in eight, had four or more ACEs. The second thing that they found was that there was a dose-response relationship between ACEs and health outcomes: the higher your ACE score, the worse your health outcomes. For a person with an ACE score of four or more, their relative risk of chronic obstructive pulmonary disease was two and a half times that of someone with an ACE score of zero. For hepatitis, it was also two and a half times. For depression, it was four and a half times. For suicidality, it was 12 times. A person with an ACE score of seven or more had triple the lifetime risk of lung cancer and three and a half times the risk of ischemic heart disease, the number one killer in the United States of America.
Studija nepovoljnih iskustava u detinjstvu je nešto što svi treba da znaju. Obavili su je Dr Vins Feliti na Kajzeru i Dr Bob Anda u CKB-u i zajednički su pitali 17 500 odraslih za njihovu istoriju izloženosti onome što su nazvali "nepovoljna iskustva u detinjstvu" ili NID. Oni uključuju fizičko, emocionalno i seksualno zlostavljanje; fizičko i emocionalno zanemarivanje; roditeljsku mentalnu bolest, bolest zavisnosti, smeštanje u zatvor; razdvojenost roditelja ili razvod; ili nasilje u porodici. Za svako da se dobija poen na NID skali. A zatim su korelirali te NID rezultate sa zdravstvenim posledicama. Ono što su otkrili je zapanjujuće. Dve stvari: Prvo, NID su neverovatno česta. 67 posto populacije je imalo bar jedno NID, i 12,6 posto, jedan od osam, imalo je četiri ili više NID. Druga stvar koju su otkrili je da postoji odnos doze i reakcije između NID i zdravstvenih posledica: što je viši vaš NID rezultat, gore su vam zdravstvene posledice. Za osobu sa NID rezultatom od četiri ili više, rizik od hronične opstruktivne plućne bolesti je dva i po puta veći u odnosu na nekog sa NID rezultatom od nula. Za hepatitis, rizik je takođe dva i po puta veći. Za depresiju, četiri i po puta. Za sklonost samoubistvu, 12 puta. Osoba sa NID rezultatom od sedam ili više ima trostruku šansu da dobije rak pluća i tri i po puta veći rizik od ishemijske bolesti srca, ubice broj jedan u Sjedinjenim Državama.
Well, of course this makes sense. Some people looked at this data and they said, "Come on. You have a rough childhood, you're more likely to drink and smoke and do all these things that are going to ruin your health. This isn't science. This is just bad behavior."
Naravno da ovo ima smisla. Neki ljudi su pogledali ove podatke i rekli: "Ma dajte. Kad imate teško detinjstvo, verovatnije je da ćete da pijete i pušite i radite sve te stvari koje će vam uništiti zdravlje. To nije nauka. To je samo loše ponašanje."
It turns out this is exactly where the science comes in. We now understand better than we ever have before how exposure to early adversity affects the developing brains and bodies of children. It affects areas like the nucleus accumbens, the pleasure and reward center of the brain that is implicated in substance dependence. It inhibits the prefrontal cortex, which is necessary for impulse control and executive function, a critical area for learning. And on MRI scans, we see measurable differences in the amygdala, the brain's fear response center. So there are real neurologic reasons why folks exposed to high doses of adversity are more likely to engage in high-risk behavior, and that's important to know.
Ispostavilo se da upravo tu nauka dolazi do izražaja. Sada razumemo bolje nego ikada pre kako izloženost ranim nedaćama utiče na mozak u razvoju i tela dece. Deluje na oblasti kao što je nukleus akumbens, centar mozga za zadovoljstvo i nagrađivanje koji je uključen kod bolesti zavisnosti. On inhibira prefrontalni korteks, koji je neophodan za kontrolu impulsa i izvršnu funkciju, ključna oblast za učenje. I na MRI skeniranju vidimo merljive razlike u amigdali, centru mozga za reakciju straha. Dakle postoje stvarni neurološki razlozi zašto su ljudi izloženi brojnim nepovoljnim okolnostima skloniji visoko rizičnom ponašanju, i to je važno znati.
But it turns out that even if you don't engage in any high-risk behavior, you're still more likely to develop heart disease or cancer. The reason for this has to do with the hypothalamic–pituitary–adrenal axis, the brain's and body's stress response system that governs our fight-or-flight response. How does it work? Well, imagine you're walking in the forest and you see a bear. Immediately, your hypothalamus sends a signal to your pituitary, which sends a signal to your adrenal gland that says, "Release stress hormones! Adrenaline! Cortisol!" And so your heart starts to pound, Your pupils dilate, your airways open up, and you are ready to either fight that bear or run from the bear. And that is wonderful if you're in a forest and there's a bear. (Laughter) But the problem is what happens when the bear comes home every night, and this system is activated over and over and over again, and it goes from being adaptive, or life-saving, to maladaptive, or health-damaging. Children are especially sensitive to this repeated stress activation, because their brains and bodies are just developing. High doses of adversity not only affect brain structure and function, they affect the developing immune system, developing hormonal systems, and even the way our DNA is read and transcribed.
Ali ispostavilo se da čak i ako ne ispoljavate visoko rizično ponašanje, još uvek imate veću šansu za nastanak bolesti srca ili rak. Razlog tome ima veze sa hipotalamičko-hipofizno-adrenalnom osom, moždanim i telesnim sistemom za reagovanje na stres koji upravlja našim odgovorom "bori se ili beži". Kako to funkcioniše? Zamislite da šetate šumom i vidite medveda. Istog trenutka, vaš hipotalamus šalje signal hipofizi, koja šalje signal nadbubrežnoj žlezdi koja kaže: "Otpustite hormone stresa! Adrenalin! Kortizol!" Tako vaše srce počinje da lupa, vaše zenice se šire, disajni putevi se otvaraju, i spremni ste da se borite sa medvedom ili da bežite od njega. I to je sjajno kada ste u šumi i tu je medved. (Smeh) Ali problem je šta se desi kada medved dolazi kući svake noći, i ovaj sistem se aktivira iznova i iznova i iznova, i pretvara se od adaptivnog ili spasonosnog u maladaptivni ili štetan po zdravlje. Deca su naročito osetljiva na tu ponavljanu aktivaciju stresa, jer se njihov mozak i telo tek razvijaju. Mnogo nepovoljnih okolnosti ne samo da utiče na strukturu i funkciju mozga, utiču na imuni sistem u razvoju, hormonalne sisteme u razvoju, čak i na način na koji se DNK čita i preslikava.
So for me, this information threw my old training out the window, because when we understand the mechanism of a disease, when we know not only which pathways are disrupted, but how, then as doctors, it is our job to use this science for prevention and treatment. That's what we do.
Za mene je ovaj podatak odbacio moju staru obuku, jer kada razumemo mehanizam bolesti, kada znamo ne samo koji putevi su prekinuti, već i kako, onda je nama kao doktorima zadatak da koristimo nauku radi prevencije i tretmana. To je ono što mi radimo.
So in San Francisco, we created the Center for Youth Wellness to prevent, screen and heal the impacts of ACEs and toxic stress. We started simply with routine screening of every one of our kids at their regular physical, because I know that if my patient has an ACE score of 4, she's two and a half times as likely to develop hepatitis or COPD, she's four and half times as likely to become depressed, and she's 12 times as likely to attempt to take her own life as my patient with zero ACEs. I know that when she's in my exam room. For our patients who do screen positive, we have a multidisciplinary treatment team that works to reduce the dose of adversity and treat symptoms using best practices, including home visits, care coordination, mental health care, nutrition, holistic interventions, and yes, medication when necessary. But we also educate parents about the impacts of ACEs and toxic stress the same way you would for covering electrical outlets, or lead poisoning, and we tailor the care of our asthmatics and our diabetics in a way that recognizes that they may need more aggressive treatment, given the changes to their hormonal and immune systems.
U San Francisku smo osnovali Centar za dobrobit mladih da bismo predupredili, pregledali i zalečili uticaje NID i toksičnog stresa. Počeli smo prosto rutinskim pregledom svakog našeg deteta na njihovom redovnom sistematskom, jer znam da ako moj pacijent ima NID rezultat od 4, ima dva i po puta veću šansu da dobije hepatitis ili HOPB, četiri i po puta veću šansu da postane depresivan, i 12 puta veću šansu da pokuša da oduzme sebi život u odnosu na pacijenta sa nula NID. To znam kada se nalazi u mojoj sobi za preglede. Za naše pacijente koji se pokažu kao pozitivni na pregledu, imamo multidisciplinarni tim za tretman koji radi na smanjenju nepovoljnosti i leči simptome koristeći najbolju praksu, uključujući kućne posete, koordinaciju nege, negu mentalnog zdravlja, ishranu, holističke intervencije, i da, primenu lekova kada je to neophodno. Ali takođe edukujemo roditelje o uticaju NID i toksičnog stresa na isti način na koji bismo to činili kada se radi o pokrivanju utičnica ili trovanju olovom i oblikujemo negu za naše astmatičare i dijabetičare na način koji prepoznaje da im je možda potreban agresivniji tretman,
So the other thing that happens when you understand this science
uzevši u obzir njihov hormonalni i imuni sistem.
is that you want to shout it from the rooftops, because this isn't just an issue for kids in Bayview. I figured the minute that everybody else heard about this, it would be routine screening, multi-disciplinary treatment teams, and it would be a race to the most effective clinical treatment protocols. Yeah. That did not happen. And that was a huge learning for me. What I had thought of as simply best clinical practice I now understand to be a movement. In the words of Dr. Robert Block, the former President of the American Academy of Pediatrics, "Adverse childhood experiences are the single greatest unaddressed public health threat facing our nation today." And for a lot of people, that's a terrifying prospect. The scope and scale of the problem seems so large that it feels overwhelming to think about how we might approach it. But for me, that's actually where the hopes lies, because when we have the right framework, when we recognize this to be a public health crisis, then we can begin to use the right tool kit to come up with solutions. From tobacco to lead poisoning to HIV/AIDS, the United States actually has quite a strong track record with addressing public health problems, but replicating those successes with ACEs and toxic stress is going to take determination and commitment, and when I look at what our nation's response has been so far, I wonder, why haven't we taken this more seriously?
Druga stvar koja se desi kada razumete ovu nauku jeste to da želite da je razglasite na sva zvona, jer to nije samo problem dece u Bejvjuu. Pretpostavila sam da onog trenutka kada svi ostali čuju za ovo, to će biti rutinski pregled, timsko multidisciplinarno lečenje, da će se takmičiti ko će imati najefikasnije kliničke protokole lečenja. Kako da ne. To se nije dogodilo. To je bila velika stvar koju sam naučila. Ono što sam smatrala jednostavno najboljom kliničkom praksom sada shvatam da je pokret. Rečima Dr. Roberta Bloka, bivšeg predsednika Američke akademije pedijatara: "Nepovoljna iskustva u detinjstvu su najveća nerazmotrena opasnost po javno zdravlje sa kojom se naša zemlja danas suočava." Za mnoge, ovo su užasavajući izgledi. Obim i razmere problema deluju tako veliko da se čini nesavladivo razmišljati o tome kako da mu pristupimo. Ali za mene, upravo tu leži nada, jer kada imamo pravi okvir, kada prepoznamo da je ovo kriza u javnom zdravlju, tada možemo početi da koristimo pravi alat da dođemo do rešenja. Od duvana i trovanja olovom do side, Sjedinjene Države zapravo imaju prilično jake rezultate u rešavanju problema javnog zdravlja, ali za ponavljanje tih uspeha sa NID i toksičnim stresom biće potrebna odlučnost i posvećenost, i kada pogledam na to kakav je odgovor naše zemlje bio do sada, pitam se, zašto ovo nismo uzeli ozbiljnije?
You know, at first I thought that we marginalized the issue because it doesn't apply to us. That's an issue for those kids in those neighborhoods. Which is weird, because the data doesn't bear that out. The original ACEs study was done in a population that was 70 percent Caucasian, 70 percent college-educated. But then, the more I talked to folks, I'm beginning to think that maybe I had it completely backwards. If I were to ask how many people in this room grew up with a family member who suffered from mental illness, I bet a few hands would go up. And then if I were to ask how many folks had a parent who maybe drank too much, or who really believed that if you spare the rod, you spoil the child, I bet a few more hands would go up. Even in this room, this is an issue that touches many of us, and I am beginning to believe that we marginalize the issue because it does apply to us. Maybe it's easier to see in other zip codes because we don't want to look at it. We'd rather be sick.
Znate, prvo sam pomislila da smo marginalizovali ovaj problem jer se ne odnosi na nas. To je problem one tamo dece u onim tamo krajevima. Što je čudno, jer podaci to ne pokazuju. Izvorno NID istraživanje je obavljeno u populaciji koja je bila 70 posto bele rase. 70 posto fakultetski obrazovanih. Ali onda, što sam više pričala sa ljudima, počela sam da pomišljam da sam možda sve naopako shvatila. Kada bih pitala koliko je ljudi u ovoj prostoriji odraslo sa članom porodice koji je patio od mentalne bolesti, kladim se da bi se nekoliko ruku podiglo. A ako bih pitala koliko je vas imalo roditelja koji je možda previše pio, ili koji je zaista verovao da je batina iz raja izašla, kladim se da bi se još nekoliko ruku podiglo. Čak i u ovoj prostoriji, to je pitanje koje se tiče mnogih od nas, pa počinjem da verujem da marginalizujemo problem jer se odnosi na nas. Možda ga je lakše videti sa udaljenosti jer ne želimo da ga sagledamo. Radije bismo bolovali.
Fortunately, scientific advances and, frankly, economic realities make that option less viable every day. The science is clear: Early adversity dramatically affects health across a lifetime. Today, we are beginning to understand how to interrupt the progression from early adversity to disease and early death, and 30 years from now, the child who has a high ACE score and whose behavioral symptoms go unrecognized, whose asthma management is not connected, and who goes on to develop high blood pressure and early heart disease or cancer will be just as anomalous as a six-month mortality from HIV/AIDS. People will look at that situation and say, "What the heck happened there?" This is treatable. This is beatable. The single most important thing that we need today is the courage to look this problem in the face and say, this is real and this is all of us. I believe that we are the movement.
Srećom, napredak nauke i, iskreno govoreći, ekonomska stvarnost svakim danom čine tu opciju manje održivom. Nauka je jasna: rane nepovoljne okolnosti drastično utiču na zdravlje tokom života. Danas počinjemo da razumemo kako da prekinemo širenje niza od ranih nepogodnosti do bolesti i preuranjene smrti, i za 30 godina, dete koje ima visok NID rezultat i čiji simptomi u ponašanju nisu prepoznati, čija kontrola astme je nepovezana, i koje razvije visok krvni pritisak i rano srčano oboljenje ili rak biće podjednako neuobičajeno kao šestomesečna smrtnost od side. Ljudi će videti tu situaciju i reći: "Šta se, dođavola, ovde dogodilo?" Ovo je moguće lečiti. Ovo je moguće pobediti. Najvažnija stvar koja nam je potrebna danas jeste hrabrost da gledamo ovom problemu u lice i kažemo, ovo je stvarno i ovo smo svi mi. Ja verujem da smo mi pokret.
Thank you.
Hvala.
(Applause)
(Aplauz)