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Hello, and welcome to “The Ezra Klein Show.”
So sometimes, you know you want to talk about a topic, but you don’t know if the conversation is going to end up worthy to the topic. But man, this one — this one delivers.
Dr. Nadine Burke Harris is the first surgeon general of California. And she’s known for doing pioneering work in the way adverse childhood experiences — what many of us would think of as childhood trauma — end up shaping the rest of our lives, the way they compound between changing our neurochemistry, changing even our biology, which genes express, and changing our mental functioning — so changing our social conditions — in this endless ping-pong of compounding physical, and social, and behavioral impact that really ends up defining a lot about what happens later — and by the way, calls really profound things, like to what degree are we responsible for our own lives, for our own choices, for what we do when presented with a situation, into question. This is really profound stuff. It turns out to affect what happens when we are children. It turns out to affect, obviously, our incomes when we get older, but whether or not we go to jail, our risk of mental health issues, our risk of addiction, our life expectancy. Profoundly it shapes our life expectancy. And it is so predictable. The more of these you have, the worse you end up doing, on average, on a bunch of these different measures. So this is really important stuff. Dr. Burke Harris has written a great book on this, “The Deepest Well.” But also, she’s just a really, really wonderful explainer of these topics. But she’s also, of course, surgeon general in California during the coronavirus crisis. So we talk a lot about that, about the vaccine rollout and what lessons were learned there, where she is more forthcoming than I had feared. We talk about the new strains emerging in California, whether or not public health officials are being insufficiently optimistic, the sort of balance between what Texas is doing — opening all the way up, I think, quite recklessly — but on the other hand, the tension of whether or not blue states, by not really providing a clear path out, are going to lose faith with the people who they need to keep trusting them for these coming months. So there’s a lot in here. I came away with this learning more than I do in the average episode. As always, my email is ezrakleinshow@nytimes.com. Here is Dr. Nadine Burke Harris.
How does trauma change children physically?
It depends on the dose. When any one of us is exposed to something scary, or stressful, or traumatic, our bodies release stress hormones. And those include things like adrenaline and cortisol. And those are associated with the feelings that we think about when we feel scared — so heart pounding, sweaty palms, all of those types of things. And that’s good. Because that helps us to mobilize against a threat. And if that happens every once in a while — the example I always give is, if you’re walking in the forest and you see a bear, right? If that happens every once in a while, that’s great, because all of these stress hormones are going to shunt blood to your big muscles for running and jumping and help you get away from the bear. They also have a profound effect on the brain. So they activate the fear part of the brain, the amygdala. And they actually turn down the front of the brain. It’s called the prefrontal cortex. And that’s where our judgment and reasoning — our seat of executive functioning. Because if you’re about to fight a bear, you don’t want to think about what those odds are like. You just want to go buck wild. [LAUGHS] And it actually turns up a part of the brain that I jokingly say is responsible for, “I don’t know karate, but I do know crazy.” Right?
[LAUGHS]
It’s the noradrenergic nucleus of the locus coeruleus, but I just call it the “I don’t know karate” part of the brain.
I’m sorry. It was the what? [LAUGHS]
[LAUGHS] It’s the noradrenergic nucleus of the locus coeruleus. But I call it the “I don’t know karate part” of the brain. [LAUGHS]
I think I’m not going to remember the other one, actually.
[LAUGHS] So all of those things are great in the short-term. But the problem is what happens when that biological stress response happens over and over again and these stress hormones are released over and over again, or it happens over a prolonged time, and it goes from being adaptive — or lifesaving — to maladaptive — or health-damaging. And one of the things that happens when we activate the stress response that’s a little bit less obvious — people think about the neurologic impacts, the impacts on how we think, and our mood, and all of those things. But our stress response also activates our immune response. And so what we see is increased inflammation, difficulty fighting off infection. And again, in the short-term, increased inflammation after a stressful experience is good. But in the long-term, it can lead to long-term health problems. And so the problem is, when you have high doses of adversity, and your level of buffering is not adequate to shut off that stress response, then what you see is increased rate of some of the stuff that you’d expect — difficulty learning, paying attention, difficulty with neurocognitive tasks, also increased risk of mental health disorders, like depression, anxiety, suicidality, but also increased risk of medical disorders, like asthma, diabetes, infections, in children, and then, over the long-term in adults, increased risk of things like heart disease, stroke, cancer, autoimmune disease, Alzheimer’s, and so on throughout life.
So I want to get at how big these differences are. So we’re talking here about a test that’ll look at how many events like this have had — adverse childhood experiences. The life expectancy of individuals with ACE scores of six or more is 20 years — 20 years — shorter than it is for people with no ACEs at all. So to put that in perspective, researchers estimate that COVID-19 reduced life expectancy in the U.S. by about a year in 2020, that curing cancer would increase life expectancy by about 3.2 years. So 20 years is a really, really big deal here. What is the mechanism that can account for such a huge difference? I understand, OK, it pushes forward use of the amygdala, pulls down a bit in the prefrontal cortex. But that’s a huge difference in life outcomes. What can account for that? What do you think is happening?
Yeah. It is a profound difference in life outcomes. And there are multiple mechanisms that are at play. And when we’re talking about adverse childhood experiences, we’re talking about 10 categories that include physical, emotional, or sexual abuse, physical or emotional neglect, or growing up in a household where a parent was mentally ill, substance-dependent, incarcerated, where there was parental separation or divorce, or domestic violence. So those are the 10 original criteria that were evaluated by the CDC and Kaiser. And that’s where this data comes from. So one of the big mechanisms that’s at play has to do with the impact of early adversity on cognitive function learning. So for example, one of the things that we saw in a research study that I performed in partnership with Stanford was that, in my former pediatric clinic, for our kids who had four or more adverse childhood experiences, they were 32 times less likely to have learning and behavior problems. And you see lower educational attainment, lower economic achievement, and the ripple effects going from there. So that’s one way. But another way is also the impact on increased risk of neuropsychiatric disorders — so increased risk, as I mentioned, of depression, anxiety, suicidality. So that impacts life expectancy. But believe it or not, the biggest impact — and this is what, I think, a lot of people miss when we talk about adverse childhood experiences — is that heart disease is the number one killer in the United States of America. Having four more ACEs more than doubles your risk for heart disease.
Why would it do that? If my parents got divorced — let’s say one of them had substance abuse — why would that change my cardiovascular health 45 years down the line?
So when your body releases the stress hormones I talked about, the adrenaline and the cortisol — and one of the things I talked about was increasing the heart rate and actually increasing blood pressure. So anytime any of us get really amped up, we feel our hearts pounding. Well, when our hearts are pounding, that actually increases the blood flow and the turbulence of blood as it goes through our blood vessels. And as it’s going through our blood vessels, the greater the turbulence, the greater the wear and tear on the insides of our arteries. Now, when you have greater wear and tear on the insides of your arteries — and then, on top of that, you remember I also mentioned there’s an impact on your immune system. You have greater inflammation. And so you have these little kind of micro-damages on the insides of your arteries. And then you tack on, on top of that, greater inflammation. And that leads to greater cardiovascular plaques. So it literally is the long-term effects of having a lifetime of a slightly overactive stress response that’s literally leading to wear and tear. The other thing that happens, we see, is that some of our DNA repair mechanisms — for example, there are things called telomeres that are at the ends of our DNA. And they protect our DNA, our cells, from wear and tear. And every time a cell replicates — so you’ve got the lining on the inside of the artery, and it’s injured, and it needs to replicate to heal itself. The more adversity a person experiences, the more it erodes the telomeres on the ends of our DNA. And it increases the likelihood that that replication will occur improperly. And so that’s why we see things like increased rate of cancer, increased rate of diabetes. So there are real, deep biological reasons why we see increased risk in not only cardiovascular disease, but actually nine out of 10 of the leading causes of death in the U.S. — so heart disease, stroke cancer, Alzheimer’s, chronic lung disease, all of these different health challenges, because of the impact of, one, increased risk of health damaging behavior — so that’s one piece. That accounts for about half the risk — and number two, the wear and tear on your body, the advanced cellular aging, increased inflammation, all of these biological processes that increase health risks.
So we’re describing here a compounding biosocial system. You have these terrible experiences as a kid. Maybe it leads to learning disabilities or distractions very quickly. That makes it harder for you to get a good job later. Or maybe it puts you in a place where you fall in with people who — you end up in jail. That creates more stress. That creates more. And so this is something where it’s kind of ricocheting back from both the physical changes it imposes on you, but then the way society treats people who end up in worse positions later on.
Yeah, that’s right.
And so when you look at these ACEs, what takes something from being stressful, like a tough experience you went through, to something that is really going to hurt you over time. When does something become — I think you’ve talked about it as — tolerable versus toxic stress? How does it make that transition?
So part of that has to do with our underlying biology. So each individual’s biological susceptibility is going to be different. You can have a family, and you’ve got five kids in the family, and one has a greater susceptibility, and one has a lower susceptibility. But the biggest difference between tolerable stress and toxic stress — or the tolerable stress response, which is activation of that stress response, but then with buffering, caregiving supports, that stress response is able to turn itself off and reregulate. When you have a trusted caregiver who can be with that child, connect with them, understand what’s going on with them, and let them know that they’re safe and it’s going to be OK, that helps to turn off our biological stress response. And it actually releases hormones in their bodies that counteract the biological stress response, hormones like oxytocin. And so even for significant stressors, if you have adequate, nurturing caregiving, you won’t see long-term negative health effects. And this is something that the National Academy of Sciences, Engineering, and Medicine wrote a report on in 2019. And one of the key pieces is, OK, so your trusted caregiver, they make all the difference in the world in being able to provide that buffering care, but the ability of a caregiver to provide that buffering care happens in the context. It happens in the context of communities. So if your caregiver is stressed to the max themselves — and we’ve all experienced this. Or at least, certainly, my husband and I have four kids. I know what it’s like when I’m super stressed out, and I’m exhausted, and I am at the end of my rope. When my child then is going through something, I’m not able to fully be there for them, right? I can’t be that buffer that I need to be. And so the caregiver makes a huge difference. But then the community context makes a difference, what kind of supports that caregiver has. Or if that caregiver is impaired for some reason — for example, if you have a caregiver with mental illness or something along those lines — what are the other supports in the community? What are the educators like? How do they support kids? What’s your faith community like? Do people in your neighborhood and community know each other, so that, if they see a child where something’s going on, they know how to recognize it and respond with that same buffering, nurturing, caregiving support that is required to help to regulate that stress response?
What makes you certain the adverse childhood experiences here are causal, not just correlational, that these studies aren’t picking up something that kids who have these experiences are also more likely to be in poverty, or come from families that have a genetic predisposition to mental illness, or all the many other things that could confound these studies?
That’s a great question. And we’ve looked at that in a couple of different ways. So first, that original adverse childhood experiences study was done at Kaiser Permanente in San Diego. Their population was 70 percent Caucasian, 70 percent college-educated. They were, for the most part, middle class. And so the original research that lifted this up really happened in a very middle class population. So it wasn’t an issue of poverty. But the fascinating thing is, we’ve looked at this across species. So this is true in rats. This is true in apes. This is true in species of fish. This is true in amphibians. It’s fundamental biology. The dose of adversity, you see the impacts on the immune system, the neurodevelopment. You see it across species. That’s number one. But what’s also fascinating about it, when we look, whether it’s a homogeneous society or a very heterogeneous society — we see this in upper income countries, lower income countries — there’s very, very consistent association between adverse childhood experiences and these negative health outcomes. We see it at the societal level. But as a scientist, I really look at it starting with the molecular level. So there are complicated research studies that are done in animals or in different species. And we see all the way down to the molecular receptor — for example, with the DNA and the changes to the methylation in the DNA with higher doses of adversity. This is measurable across species, including humans, all the way from the molecular level to, we see it clinically, in terms of manifestation of disease. And then we see it broader, in terms of the impact on our society.
So I want to get it some of the philosophical implications of this. And to lay my own cards on the table here, I’ve been interested in this kind of research for a long time. I’ve done episodes with Robert Sapolsky and Sendhil Mullainathan, who have done sort of similar work on stress and stress response. And I always come away thinking that this is a pretty profound challenge to the way we think about and structure society. So much of public policy thinking is based on this idea of personal responsibility, that it’s our choices that determine our life outcomes. But if our choices are determined by our cognitive development — and of course, they are — and our cognitive development is shaped so much by forces, and events, and traumas that are outside of our control — things that happen to us as little kids — what does that end up saying about this idea that we are in control of our own lives, at least to the extent we like to believe?
In my opinion, this is as big as a germ theory. Back in the day, we believed that infections were caused by bad airs. And so we did things to alleviate those bad airs, like opening the windows and doing other stuff. But we didn’t do things like wash our hands, or cover our mouths when we cough, or anything like that. And as germ theory was discovered, it led to a change in the way that we organize society. We did things like sanitize water instead of dumping human waste into the water supply. We were like, oh, that transmits germs — all of those things. And that’s where science shaped society in a really profound way. I think that this science should — I would go so far as to say “should —” shape society in a similar way. Because when we understand that early adversity has a profound effect on long-term health, cognitive development, risk of, like I said, nine out of 10 of the leading causes of death, then it requires us to implement the policies and practices that are responsive to that science. And the science that undergirds the research around ACEs, this emerged, really, in the last 20 to 30 years. Our ability to measure the ways in which early adversity affects the expression of our genes, that was genomics and epigenomics that we discovered in the last 20 years. So that piece, in terms of people not knowing this before, I completely get. But now that we know better, it’s our responsibility to do better. And the important piece of it that I would say is that this science gives us information about how we do better. And that’s why it’s so powerful. Because early adversity does not have to be deterministic. Now that we understand how we go from exposure, to early adversity, to worse outcomes, whether it’s educational outcomes, incarceration, physical health, or mental health — any of the above — then I believe we have an obligation to put that science into practice to save and improve lives.
Let me hold on incarceration for a second. Because that’s, I think, a good place where you can see sort of the challenge this poses. So one of the ACEs or ACEs, I guess, is what I’m supposed to be saying, is having a parent incarcerated. When we incarcerate a parent, in addition to holding them responsible for their actions, which may be partially mediated through childhood trauma themselves, we are, now we know, punishing their children pretty profoundly. We’ve always known that on some level, right? Your parent is gone. There’s less money in your household, et cetera. But we now know we are shaping their cognitive development in a way that is going to likely make them poorer, more prone to mental illness, more prone to being incarcerated themselves. That is a crazy thing to visit upon somebody completely innocent in a crime. And so then it creates this question. Is incarceration itself making the very problems we are trying to solve worse? How does it change one’s view towards something like incarceration?
I will say the way that it changes my view towards the incarceration, which is that, when we look at the data around adverse childhood experiences and incarcerated populations, what we see is, there was a big study in Florida looking at over 60,000 incarcerated youth. And 50 percent of them had four or more adverse childhood experiences. That’s compared to nationally, where we see about between 13 percent to 17 percent with four or more ACEs; 96 percent had at least one ACE. Now, if we know that ACEs lead to the development of the toxic stress response, which is a health condition, the question that comes to my mind is, you have to recognize that there are real public safety issues at play. And of course, we want to safeguard the public safety. But it hearkens back to back in the day, when folks with mental illness, we would just lock them up. And understanding that toxic stress is a health condition that is treatable, especially with early intervention, and shifting from a societal structure that seeks to essentially contain and chastise — I mean, we want to protect public safety. So I want to be really clear about that. But I think that it would indicate that perhaps a more important tool would be to identify individuals early and actually do treatment.
I think this also should make you wonder about how we treat the successful in society. And I guess I’ll use myself as an example here, rather than putting this on anybody else. I’m considered successful. I’m paid well because I’m good at reading, and synthesizing, and concentrating, and sorting information. But a lot of that just feels pretty innate to me. It’s not something I chose that other people didn’t choose. I tried to make good choices on the margins. But I had divorced parents. But I had wonderful caregivers. And I don’t have a lot of other marks on the ACEs measure. So I think a pretty damn good argument could be made — and I’ve always felt this — that a lot of what has led to my life going well are not choices I particularly made, but the context in which I was raised and the way that shaped me. I don’t make myself concentrate on this stuff. I somehow can. And if I couldn’t, I just wouldn’t. So how does it make you think about what credit the successful deserve, or maybe what they owe to those who did not have the opportunities they did?
Yeah. I think about it in a couple of different ways. One thing I want to acknowledge and highlight, which I think is really important, is that there are plenty of successful people with lots of ACEs. Part of the reason why I think this is so important is because, even among folks in the upper income realm, we still see increased risk of things like cardiovascular disease, and stroke, and cancer, and all of those pieces. But I think the point that you’re making has to do with the way that our society has structured the odds that an individual will encounter adverse experiences versus the odds that an individual will encounter supporting, enriching experiences. And those odds make a difference. They make a life-and-death difference. So when we under-invest in certain communities, and when we see the odds stacking up against certain communities, it has profound life-or-death differences and outcomes. To answer your question of “how do we look at those who have done well versus those who have struggled,” I want everyone to do well. I want everyone to have those same odds, to have those same enriching touches, relationships. One of the things that I talk about often is that we know that the cumulative dose of adversity has a profound impact on brain development, immune system development, long-term odds. We also know that the cumulative dose of buffering and enriching experiences does the opposite. And it sounds like you had a good, solid cumulative dose of enriching experiences and relationships. And everyone deserves that. I want to just give an example of how these things compound. We recently saw, in Rochester, where police were called to a situation of domestic violence. And when they got there, they encountered this nine-year-old girl who’s running away from the police officer who clearly is in full fight-or-flight mode. And this nine-year-old ends up being pepper-sprayed. So that is trauma on top of trauma. And that is where the differences in the way that our society responds to people — and I think that race plays a huge role in this. As a nine-year-old black girl, I think that, if she was in a community where the officer called to the situation comes on scene, sees that something awful has happened, and immediately recognizes, wow, this little girl needs my support, I need to be a buffer in this moment, instead of laying on the pepper spray, that is the difference in the cumulative dose. She had witnessing domestic violence. And then throw on top of that being pepper-sprayed by police. She could have had witnessing domestic violence and then getting a dose of buffering, getting a dose of understanding, getting a dose of deescalating and support. These are the profound differences that add up over time.
There’s a debate right now in Washington about whether to do child allowances, and also whether to construct welfare benefits more broadly and social insurance benefits, whether those need to be linked to work or not, whether we want it to be possible for, say, a single parent of three kids to make the choice to stay home for a year and a half when their kid may need them, or whether we think it’s so important they go into work that we’ll even push them into low-wage labor at the point of child poverty. I’m wondering how you think about that debate, particularly in light of the importance of having caregivers around.
Yeah. So this is something that the national academies also weighed in on in their “Vibrant and Healthy Kids” report. And so what the research shows is that child poverty really hurts childhood health and development. That’s clear. And so what we see is that support for parents is very important. And specifically, money matters. And so from that standpoint, I would say that policies that are designed to support parents to be able to parent, to be present with their kids, to be able to reduce some of the stressors of, especially, parents who are at or near the poverty level — so to reduce that child poverty is very important.
I think another direction one might take this is, given the prevalence and power of past trauma in society, pretty big investments in mental health care, for children and for adults, would make sense. I’m curious if you agree, but more to the point, because people sometimes say this, if we know how to do that well, if we have a sense of how to make big investments in mental health care such that the care people are getting actually helps them, actually gets to them, and actually has an effect.
So in our society, it feels like we have this odd disconnect that happens at the level of the neck, right? [LAUGHTER] So if there is a health condition, if you’ve got all kinds of stuff, it’s covered. There’s lots of debates about that. But generally speaking, that’s the accepted practice. And then, with our mental health, for some reason, it gets a different treatment, and we see different dollars allocated. And what’s interesting about that is that implementing accessible, high-quality mental health care — and I’m going to say not just mental health care, but preventive mental health. Mental health has this weird category where we do almost no prevention. And we know that there are a lot of things that we can do to do prevention, like doing screening and early detection and early intervention for adverse childhood experiences. I think that therapeutics is a huge frontier that we need to be investing in a great deal more than we are right now. A lot of the therapeutics, particularly when it comes to the impacts of trauma, the impacts of ACEs and toxic stress, so many of the therapeutics are targeted very, very downstream. So you have these long-term health conditions where you have one brain cell that’s not making enough of a neurotransmitter, and so we’re going to try and support the production of that neurotransmitter. It’s like the very end of the line, when the opportunity that I think this science of adverse childhood experiences and toxic stress offers us is that we now understand much more of what happens in many of the steps leading up to that. And I think that that offers us an important opportunity at therapeutics. One example that I think is really fascinating is, I mentioned that oxytocin helps to interrupt the response. And one therapeutic that some folks have done some research in is looking at oxytocin. For example, they have it in nasal spray form — things like that. That level of using the science and targeting the molecular mechanisms or using that to develop therapeutics I think is critically, critically important. I think that we need more research into these fields that really target the root cause. And I think that that is an important scientific frontier for the 21st century. [MUSIC PLAYING]
So we’re all living through this collective trauma of coronavirus right now, some of us more than others, of course. But so too are children, some of them who understand what’s going on, some of them who don’t. Do you think that coronavirus is going to be a societal ACE, at least for this generation of young people? Or is it more complicated than that?
So when I use the term “ACE,” I’m referring to the 10 categories in the ACE study. But whether I think coronavirus is a risk factor for toxic stress, I would say, almost for sure. The reason for that is because we see that ACEs themselves are going up. So we know that ACEs are causal of the toxic stress response. There was a report from the Kaiser Family Foundation that the number of folks that were reporting mental health condition went from 10 percent in June of 2019 to 40 percent in February of 2021. I mean, it’s just outrageous. We see increased rates of intimate partner violence. We’re seeing increased rates of folks experiencing economic hardship, which we know is also a risk factor for the toxic stress response. So almost undoubtedly. I mean, even in terms of things like child maltreatment, where, when shelter in place went into effect, the rates of reports of child maltreatment here in California and across the country dropped by about 40 percent to 50 percent. And that doesn’t mean that child maltreatment went off a cliff the minute that everyone got really stressed out about a pandemic and schools were closed. It means that the likelihood is that we have unreported child maltreatment. And actually, the CDC was showing that the severity of child injury for those kids who do have to go to hospital has gotten worse. So ACEs themselves are going up, which means that toxic stress will go up. But the pandemic itself is a major stressor. And that’s driving some of what we see, in terms of this increased risk of mental health, and increased risk of substance use and dependence, and things like that. And so there’s a double whammy. There’s the stress itself from the pandemic and the fact that the pandemic also leads to other stressors, which then, again, is this cumulative dose. So we see that the cumulative dose during this pandemic is dramatically increased. And I think that that gives us an indication of how important it is for us to be investing in trauma-informed cross-sector solutions, not just in health care, but across the board.
Without letting me expand the ACE categories on the fly — [LAUGHS] — one of the things I’m interested in here is whether or not coronavirus is going to change kids who grew up amongst it. So I have a two-year-old boy. And he has barely seen his family, beyond me and my wife. He has only known a world where people walk around in masks and don’t come near each other. These are crucial years of socialization. And his has been really different than it would have been outside of this context. Now, and he’s been lucky. We haven’t lost an immediate member of our family. We haven’t lost our jobs. There are a lot of kids who have been in a lot less lucky families, as some of the research you were just talking about shows. Do you think this is going to change this generation of children? I mean, these are important years. Everything you’re saying is that things that happen early to us reverberate late. It’s a pretty big thing that happen to all of us. Do you think we’re going to basically have a coronavirus generation?
When we look across the society, I think the answer is going to be, yes, in a manner of speaking. And the good news is that children do have a profound capacity for resilience. And you and your partner have an incredible capacity to make meaning for your child, support and buffer the stress for your child. So they may have a worldview that is shaped by the pandemic, but in terms of their individual risk of long-term negative health consequences, I think the likelihood is that your kids are going to do just fine. Because we know that kids, when they have that buffering, nurturing caregiving — my kids are going to do fine. There are many, many, many children, and a significantly increased number of children, who don’t have that level of buffering. When we talk about, for example, children whose parents are essential workers who face the issue of, you either go to work or you don’t have a job, they’re stressed out about being exposed to COVID. That stress comes home. Or even worse, their parents get laid off. There’s economic anxiety. There’s stress, depression, all of those pieces. Those kids are going to have significantly increased risk of long-term negative developmental, educational, health, and mental health consequences.
I want to get something you said there, which is that the aftermath of this will be uneven, that this is a societal calamity, a global calamity. But not every part of the globe experienced it the same. And not every part, certainly, of our very, very unequal society experienced it the same. How should that inform our policy? We’re about to talk about sort of immediate coronavirus policy. But if you were to think about the actual rebuilding out of this, the trying to calm the long-term damage it could do, how would you think about that?
So this is what we wrote about in the surgeon general’s report “Roadmap for Resilience.” And that’s where the cross-sector response is so critically important. Because that is where the cumulative dose of buffering that we deploy in our society is critically important. It is critically important if our educators, and our law enforcement, and our judges, and our early childcare workers, and the guy at the grocery store understand how they can be part of the solution, how they can be a source of buffering for a child. It is critically important that we are making investments to support those families and those communities that are disproportionately impacted. Because it is a matter of long-term health and well-being for this generation. When we’re talking about a major generational trauma, we recognize that we have to implement supports, trauma-informed systems. Because we know now that we’re going to see a generation with these impacts if we don’t do anything.
So I want to talk a bit about the California coronavirus response now. So the vaccine rollout efforts began, at least according to the data, a little bit slowly in December and early January. But they’ve picked up a lot now. The state is above the national average, with about 16 percent of Californians having received a first dose of the vaccine. What lessons got learned here?
Simplicity saves lives.
Tell me more.
We had a really, really well-thought-out strategy on rolling out the vaccine, particularly with a strong eye to equity. Listen, equity is our North Star. But one of the things that we recognized was that it was challenging to implement at the end-user level. And in California, we have an amazing public health system. Much of it is focused at the community level. So we have 58 counties. And our local departments of public health really are connected and in tune with the needs of their local communities. But it became challenging for folks to understand whether they were eligible, where they should go, how they would understand what their eligibility is, and the implementation on the ground. Because it was happening at our local public health level. Folks oftentimes were confused about the differences between rules that were happening in one county versus another county. So we listened. We heard. We got lots of feedback. And that’s the good news about working in government. When you’re doing something, and folks feel like it’s not going great, they let you know. So that’s fantastic. And the things that we heard was, number one, we needed a simpler system for eligibility and understanding eligibility. Number two, we needed to have a more streamlined system that was easier to operationalize for vaccinators on the ground. And so we made a transition. We created the My Turn system so that anyone in California can go myturn.ca.gov and find out if they’re eligible. And if they’re not eligible, they can put in their information to be notified when they will be eligible. And if they are eligible, they can make an appointment to a local vaccination center. We also moved to a third-party administrator, where, really, the goal is to support the excellent work that’s happening at our county level, but streamline and clarify our vaccination deployment strategy. And so we’re in that process now of transitioning to a third-party administrator who will help us to be able to deploy vaccine quickly, efficiently, and, very importantly, equitably.
So one evolution I’ve noticed here is, when the vaccination efforts started, there was a reasonably complicated eligibility formula or framework. That got simplified and pushed much more sort of towards a direct age framework. And then, more recently, the way I’ve seen California trying to push towards equity and certain goals is by allocating more vaccines for certain subgroups — so 10 percent for educators. I was on a call this morning with your colleague, Dr. Mark Ghaly, that I think there’s a doubling of the allocation for the lowest quartile of places in the California Healthy Places index. They have, I guess, 40 percent of the deaths, 25 percent of the people, and only 16 percent of vaccinations, compared to 34 percent among the highest quartile places. Can you tell me a bit about that, and also why you feel that’s not going to undermine simplicity this time, that it will be consonant with that continued fast rollout?
So to answer your first question, yes. So when it came to rolling out vaccine, we did what just about everyone else in the country did in terms of phase 1A, which was prioritizing our health care workers and those in long-term care facilities. And of course, the reason for that is because we need to vaccinate the vaccinators. We need to shore up our health care infrastructure as a very important first step. But the problem is that our health care providers are predominantly folks who are in the upper income realm. They’re predominantly less likely to be people of color. And so when you vaccinate your health care providers first, and then you get to the end of the point, and look at who across your population has been vaccinated — no surprise — we see that 2.9 percent are African Americans. We see that of the folks who have been vaccinated, only 16 percent are in the lowest HPI quartile. And that’s because we had to shore up our health care system. And so the next immediate step for California was being able to say, OK, now that we’ve done that crucial step, how do we address these inequities? And so we look at it. And it’s an equity framework. But it’s also just a smart public health framework. Because when we see that almost 40 percent of cases are happening in the lowest 25 percent of the population, in terms of our Healthy Places Index, it’s just smart public health to put more doses there. We are allocating doses proportionally to the disease-burdened. So it’s the right thing to do, both from an equity standpoint, but also from a public health standpoint. And it’s frankly our fastest way through this pandemic.
Yeah. I mean, this is something that I was thinking about. People, I think, sometimes think of equity and speed as being in tension here. But if you can’t get at the communities where 40 percent of the cases are and 40 percent of the deaths are, then you’re not going to get the numbers down that quickly.
That’s the thing. In this case, equity is speed. If people want to reopen their businesses more quickly, we have to target more doses to where we see the disproportionate burden of disease. Because that’s what’s keeping communities from being able to re-open. And so this is smart from an equity standpoint, from a public health standpoint, and from an economic standpoint. Because we want to quell the spread so that we can reopen society. To answer your second question — why is this going to work when the other one didn’t work — it has to do with front office versus back office. So the previous system was this question about eligibility, and how do you figure out if someone is eligible, and what sector. So for example, when we’re using a sector-based strategy, which has some strong equity principles built into it, one of the big challenges is, how do you verify eligibility? What if someone is a childcare worker, but they work watching their cousin’s children — all of these different things. When we address equity through our allocation, that’s a back office thing. It doesn’t require someone who’s at that table checking people in to be able to do anything different from what they’re doing on a day-to-day. What this strategy does is streamline a lot of the back office stuff. So for example, that MyTurn system where folks sign up for appointments, we can open up more appointments in these zip codes with the lowest HPI quartile. That’s a back office function. It’s not more difficult to implement. It just someone on a computer programming the My Turn system to open more appointments. And it minimizes confusion. It minimizes the work of operationalizing it while still achieving these equity objectives.
So you mentioned that part of the reason we’re seeing this big disparity — 16 percent of people in the low Healthy Places Index places being vaccinated and 34 percent in the highest quartile being vaccinated — is partially there are a lot of health care workers that live in that high quartile, which I’m sure is true. But I’m sure there are others too. So I’m curious what, in your experience, have been the bottlenecks here. Things that I have seen even just around me is, people with resources are really trying to push the system. They’re better at trying to game out the digital pieces of the system. They flow to loopholes really, really quickly. But I’ve also heard a lot of things from people on the ground about more vaccine skepticism in some of the communities that you most need to reach. I’ve seen this in my own direct contact with people. So is the problem in the lower quartile communities supply? Is it distribution? Is it public concern about the vaccine itself? Is it all of them? What do you see as the chokepoints?
It’s all of the above. It’s not one thing. So certainly, folks who have more time and more resources can get on a computer — if they have high-speed internet, it’s even easier. If they have a computer, it’s even easier — and hit refresh and get an appointment. And so when you have a system where there are challenges or it’s difficult to navigate, that’s always going to bias for people who have more resources and more ability to navigate the system. If you have a car, and you can drive 20 miles to get vaccinated, that’s going to be even easier. If you can take time off of work, and you can go ahead and grab that appointment at 2:00 in the afternoon, it’s going to be even easier. So all of those things we are addressing through partnerships with community-based organizations to help folks who have more challenges be able to sign up through utilizing patient navigators, and promotoras, and others to help. Because if you’re non-English speaking in California, our My Turn system is rolling out in multiple, multiple languages. And you can go online, or you can just call the phone number. You don’t even have to have a cell phone. You can call from a landline. Someone else can make the appointment for you. So we’re trying to do it to make that as easy as possible. And at the same time, there are real issues about hesitancy. And when we talk about hesitancy, I think that, as someone who spent my professional career working in a very, very vulnerable, very under-resourced community, which is the Bayview Hunters Point neighborhood in San Francisco, I have had a lot of experience in understanding what are some of the obstacles for individuals in communities, in terms of trusting the health care system. Now, some folks have vaccine hesitancy for lots of different reasons. There are the folks who say, I’m worried about the safety and efficacy. There are folks who just generally are skeptical of vaccines to begin with. And then people talk about the history of, for example, mistrust of the health care system. And especially when we talk about African-Americans, folks frequently cite Tuskegee. Tuskegee is important to acknowledge, but the reality for most of the folks that I’ve served throughout my career is not about Tuskegee. It’s about their day-to-day experiences when they go to the doctor today. And this is something I will say as a black woman. This is something that I’ve experienced myself, of going to the doctor and sitting there, being like, I don’t feel like I’m being listened to right now. I don’t feel like I’m being heard. I don’t know if I’m being well-served. And I’m a doctor! And I’ve seen it happen patient after patient after patient, family member after family member coming to me as I was caring for families in a community clinic in Hunters Point. Hey, Doc, I know that you’re here for my kids, but let me tell you about this problem that I’m having in my own health care. And there are so many ways where I had to be not only a physician to my patients, but an advocate for the community. So I think that’s real. I think that there are many people who have an experience of health care today that has not been equitable. And that is something that we, as a health care system, really have to deal with. Because we’re dealing with it now with a pandemic. We’re trying to achieve community immunity. But it requires that people feel like they can trust our health care system. So I think that’s important. Then there’s always just straight up misinformation and disinformation. And that’s why we’ve got to do effective public education campaigns. Because people say all kinds of crazy things. And you’ve got to debunk those things. So it’s all of the above.
How do you deal with not just, as you put it, long history, but personal history of reasonable mistrust at pandemic speed? That sounds like a problem that it would take a really long time to change our attitudes about. And we want to get people vaccinated right now.
So what you have to do in those situations is, you have to take the ingredients that it’s going to take to solve that and figure out how to put them together. Because trust takes time. And we’re not going to solve trust in pandemic speed. That’s why we have to partner with trusted messengers and trusted providers. And we have to support them with resources. So we take the trust, and we find out, how do we couple the trust with the support? And then how do we couple the trust and the support with the capacity? And we put it all together. And that’s what we are doing here in California. So we just invested $52.7 million in 337 community-based organizations. And that is to help those folks with whom folks have had a relationship for a long time to give them the resources, the tools, what they need to be able to leverage that relationship to say, oh, OK, and now I’m going to help you get an appointment. [MUSIC PLAYING]
So there’s been a lot of talk recently about these new COVID-19 variants. People have heard of British ones and South African ones. But there’s also been some in California. There’s some worry that they’re more transmissible. What do we know about them? Are they changing the plan at all? Should they change how people are thinking about this?
So we are tracking the variants. They’re certainly of concern. And we are doing surveillance and sequencing of the different types of variants. And I think that the short story is that they don’t change the strategy. It makes some of the fundamentals of tackling a pandemic even more important. Wearing a mask, watching your distance, waiting to gather, washing your hands — all of those are critically important. And it also makes the importance of the vaccine. So the more the virus spreads, the more it replicates. The more it replicates, the more the opportunity for it to develop new variants. And so a strong vaccination campaign is the best offense against this. Now, one of the things that I think is really positive is that the Johnson and Johnson vaccine that was just approved that was studied in South Africa — and we see that it has 85 percent effectiveness against severe disease, 100 percent effectiveness against death from COVID. And that was investigated at the time when we were seeing the South Africa variant, which is one of the variants of concern. And so that’s really positive, that we see some evidence of efficacy against that variant. But it doesn’t change our strategy now, in terms of doing the same things that we need to do to prevent the spread.
So I was a lot more pessimistic six weeks ago, let’s call it, when these variants were spreading. But then something that has been really striking to me — and obviously, not just to me — was the massive and basically global plummeting in coronavirus cases, including in places like Britain and Portugal that had the B.1.1.7 strain, including places like California that seemed to have a particularly dangerous strain, practically in the LA area, in places like South Africa. And yet that’s happening across jurisdictions that have different whether. It’s happening across jurisdictions that have really, really different policy equilibria. It’s happening in places that are vaccinating and places that are not. Why did it go down so rapidly in so many places at the same time?
A big part of the reason why it’s gone down so rapidly is because, when we saw these huge surges, the response was significant tightening of public health measures. So here in California, we had our regional stay at home orders. And that was really looking at our thresholds. Because we were facing an issue of zero ICU capacity in certain parts of the state and very limited hospital capacity. And I think that that’s what we saw. I think that, when cases were surging, we deployed, in large scale, the most powerful tool that we have against this virus. And that is human behavior. I think that when folks see in the news and they hear cases rising, rising, rising, rising, I think individuals begin to calculate what the risk is of going out and going to that gathering. And we see changes in how that calculation comes out. And we also saw jurisdictions around the world tightening some of those public health regulations. And I think that has really made a difference.
So you probably saw that Texas is opening back up entirely. No more masking. Nothing is closed at any level. I think that’s pretty clearly reckless. But I was watching the reaction to that among liberals I know. And something I worry about is that maybe blue states are not offering a clear enough vision of what a responsible end to this looks like. Public health officials are oriented towards caution. I was on the call with Dr. Mark Ghaly. He said, this is not a stepping on the gas. We’re keeping our foot on the brake. Do you worry that you’ll lose people if they don’t believe there’s an end to this, that they’ll flock to the politicians who tell them there is if they can’t see where the light at the end of the tunnel is in the plan or the politicians they currently have?
I worry more about easing restrictions too early and having another major surge. And I think that people get tired. We see this. We certainly saw this here in California, where we saw a really nasty surge over the holidays. People get tired. And it’s hard to tell people that we need to hang on a little bit longer. To your point, I think we probably could do a clearer job in helping folks visualize where the finish line is. And I think one of the things that’s really challenging is that, for example, we all had in our minds that the vaccine comes, and that’s the finish line. And then we started seeing the emergence of variants. And we said, well, the emergence of variants, how does that impact what we do? And now we’re believing that we have to see. We have to understand. And at the same time, I do think that vaccine is going to make the huge difference. And I do think that when we get to community immunity — and the hope there is that, hopefully, in the summertime, we’ll be reaching some of those levels of herd immunity that will be meaningful in terms of changes in our day-to-day lives. But we’re always learning more information. And I think, as public health folks, we also want to make sure that people feel like we’re credible. Because we’re giving them science-based, good information.
Yeah. And one conversation that I feel like is going to need to be had, but is going to be hard for all of us who have spent the last year really worrying about this and building an identity as people who take it seriously, is, what is an acceptable level of risk for you for a community? Because this is not going to end with risk at zero, given strains and other things. There’s a risk of catching the flu, and people die from it. There’s a risk of getting in a car accident when we get in the car. But I don’t know that even I understand the level of risk that public health officials would be comfortable with in normal, everyday life, with a return to normal, everyday life. And I cover this professionally. So how do you think about that level of risk? Or even just how do you think about communicating that there’s a level of risk that is acceptable?
It’s definitely not about getting to zero risk. Because that’s not feasible. We recognize that there are trade-offs to the decisions that we make about risk. But I do think that we know that there is a certain level of herd immunity — about 75 percent of the population is what we believe it is for COVID-19, based on its infectivity — where it becomes much harder to spread this virus. It becomes much harder for the virus to move through a population. And that’s when we get to the point where it feels like it’s kind of acceptable to go back to our day-to-day practices. And that is a pretty reasonable standard. It’s not that COVID-19 has to be completely eradicated from our society. I mean, that would be awesome. But we have good science to tell us that, at a certain point, the risk to the individuals, the risk to society, and, more importantly, the risk to those individuals who cannot get vaccinated for whatever reason goes dramatically down. And that’s where we’re trying to get to.
I think it’s a good place to come to a close. So let me ask you for a couple book recommendations here at the end, and I appreciate all the time you’ve given me. Let me start here. You’ve written, obviously, a wonderful book on ACEs, and children, and stress. But if you’re just somebody who wants to understand the stress response and how it works on the body, what book would you recommend?
“Why Zebras Don’t Get Ulcers” by Rob Sapolsky.
So good. So good.
It’s one of my favorite books!
I’ve talked to Robert Sapolsky. That’s a great book I cannot reccomend enough.
It’s awesome.
You’ve done so much work on children and what they need. But as we’ve talked about, so much of that is about being a good caregiver. What would you recommend, or what book do you recommend, to new parents?
Oh, to new parents, this is going to be a slightly geeky response, but “The Emotional Life of the Toddler” by Dr. Alicia Lieberman. My husband and I have four boys. And I read it when our fourth was a baby. And I was like, oh, my god, why didn’t I read this before? [LAUGHTER] It was awesome. Yeah.
All right. I think I’m sold on that one. I’ve got a two-year-old, and I would like to understand that emotional life a little bit better. [LAUGHS]
Oh, definitely.
You deal with tough situations in your work. What book makes you feel better when you read it?
So I would say the book that I’ve read in the last year that made me feel better was a book called “The Woman Behind the New Deal.” It’s about Frances Perkins, who was the first woman in the cabinet. She was FDR’s secretary of labor. And I loved that book. It was so inspiring. And to read about all of the challenges that she faced both personally and professionally and the way that she persevered, and the fact that, because of her efforts, we have social security, unemployment insurance, 40-hour work week, time and a half for overtime — things that didn’t exist — worker protections, sprinklers in factories — things like that where you’re just like, damn, Frances Perkins! So I feel like, if anybody’s out there, make a movie about this book. Because Frances Perkins was the bomb.
That’s a great recommendation. And then finally, you’ve got four kids. What’s your favorite children’s book?
“Runaway Bunny.”
[LAUGHS]
Yeah. That’s the one where the little bunny decides he’s going to run away. And every time, he says, I’m going to become a fish, and I’ll swim away from you. And the mom says, well then I will be a fisherman, and I will catch you in my net. It’s just about a mom who is always there for her child. And that’s what I strive to be.
Oh, that’s lovely. Dr. Nadine Burke Harris, thank you so much.
Thank you, Ezra. It’s been a pleasure. [MUSIC PLAYING] So can I just say something really funny? You do look a lot like Vivek Murthy. [LAUGHS]
I knew what you were going to say, yeah. [LAUGHTER] That’s weird.
Yeah. It’s a lot.
“The Ezra Klein Show” is a production of New York Times Opinion. It is produced by Roge Karma and Jeff Geld, fact-checked by Michelle Harris, original music by Isaac Jones, and mixing by Jeff Geld. [MUSIC PLAYING]