Congratulations. You have just been appointed Surgeon General of the United States Public Health Service—top dog and top doc over the Centers for Disease Control and Prevention in Atlanta. Here’s the catch: The POTUS told you in his Oval Office chat before his announcement that your survival in the job depends on your choosing one issue to target that will dramatically drop a) chronic disease rates for diabetes, heart, and lung diseases, b) severe mental illness rates, c) substance abuse rates, d) crime rates, and e) stay budget neutral. The POTUS wants a bigger bang for the buck than we got with the last target issue, smoking, thirty years ago. What’s your magic bullet, Surgeon General? He generously gave you a week to choose.
Before you resign for the familiar comforts of civilian life, you scribble a list to talk over with your eager advisers: obesity, gun violence, heroin, diabetes, Alzheimer’s, cancer. The list is too short. The data don’t fit his criteria. POTUS is a dreamer. There is no magic bullet. Your advisers agree with you. They advise you this is just the first of what you can expect to be a series of setups to test your political mettle.
You sleep badly that night, but like a good soldier you show up at work the next morning. There on your desk is a worn and marked copy of The Body Keeps the Score: Brain, Mind and Body in the Healing of Trauma by Bessel van der Kolk, MD (2014). A bookmark between pages 346 and 347 lures you to the Epilogue: “Choices to be Made.” It’s only 10 pages, and you read it as if it could save your political career.
Van der Kolk argues that childhood trauma, in the form of adverse childhood events, child abuse and neglect, “is the single most preventable cause of mental illness, the single most common cause of drug and alcohol abuse, and a significant contributor to leading causes of death such as diabetes, heart disease, cancer, stroke, and suicide.” It’s a hefty book. The author’s an academic clinician, has done some homework and some trenchwork. Been at it for 30 years. Tells a good story. A Dutchman who reminds us that plenty of northern European countries have figured this out. They provide better maternal and child care, universal health care at lower costs, and have lower crime rates with one tenth the incarceration costs we pay for in the US.
A pink sticky tab on p 167 draws you to a quote you write down for your next meeting with your advisers: “Economists have calculated that every dollar invested in high quality home visitation, day care and preschool programs [for high risk children] results in seven dollars of savings on welfare payments, health-care costs, substance abuse treatment, and incarceration, plus higher tax revenues due to better-paying jobs.”
You cancel both your appearances at ribbon-cutting ceremonies and spend your day scouring the book, making calls, unleashing your fact-checkers on the book’s major claims, and buying van der Kolk a ticket to Atlanta. The next day your first question to your advisers is why childhood trauma is not on their short list. They look at each other and then at you with that unmistakable message of polite condescension that reminds you that you are the newcomer in the room. When you demand a translation, the epidemiologist to your right speaks up: “Sir, we’re bound to prioritize the high prevalence conditions. Childhood trauma has not been operationalized as a diagnosis, beyond PTSD, which is a low prevalence condition in the general population, relative to our major players such as diabetes, obesity, heart disease.”
You pull out the book and turn to page 348 and say, “What do you make of this epidemiologic statement: ‘Since 2001 far more Americans have died at the hands of their partners or other family members than in the wars in Iraq and Afghanistan. American women are twice as likely to suffer domestic violence as breast cancer….Firearms kill twice as many children as cancer does.’ Doesn’t that make trauma a high prevalence condition, whether they have PTSD or not?”
The room is quiet. Is it the steamy heat or do they seem to be squirming? Finally, the epidemiologist says, “The politics of childhood trauma are likely to be tricky, sir.” Then it dawns on you. Everyone in the room is feeling what you’re feeling: shame. This is an ugly topic. And we don’t want to talk about it. We ignore the evidence, even high-level experts ignore it, because it’s shameful what happens to “our kids.” We ignore childhood trauma because we assume that it’s not a health condition that we can do something about. But you remember when CDC elevated gun violence in the 1980’s to a public health condition that deserved prevention efforts. Why not childhood trauma?
You ask who left this book on your desk; none of them claim the deed, though most of them are aware of the book. When you ask Mrs Deets, your portly administrative assistant and the sage of CDC for the past two decades, she smiles and says, “I heard you have a difficult choice to make, sir. Now is there anything else that runs so deep in our culture? That book came my way last year after I lost my grandson to heroin.” It’s all there in her voice, a voice that sounds like Toni Morrison reading Beloved, the voice of women who grew up in the long shadow of slavery and domestic violence. Looking at Mrs Deets, it’s hard to imagine how you could have missed this truth about what ails our country most. It’s hard to believe that as recently as yesterday you wondered about the choice.
What if we allotted the same amount of resources to children with high childhood trauma exposures as we allot to children with other high-risk chronic conditions, such as cancer, cystic fibrosis, muscular dystrophy, or severe intellectual disabilities? What if the high-risk children exposed to trauma were enrolled in programs that facilitated pre-school participation, case management through grade school and high school, tutors to reduce school dropout rates, family access to social workers and childcare and mental health services and vocational rehabilitation? He said “budget neutral!” So where would the money come from? Department of Corrections, Medicaid, unemployment, DEA and ATF payrolls, police force payrolls. For every dollar spent, seven dollars saved? Get the economists to run the numbers. The POTUS will need fresh numbers.
Then a smile ripples through you. Maybe he already has the numbers. Maybe he has read the book.