The Deepest Well: Healing the Long-Term Effects of Childhood Adversity

Burke Harris opened her practice, Bayview Childhood Health Center, because she hoped to reduce disproportionately high rates of illness (health disparities) in the community. One of her early patients was a seven-year-old boy named Diego, whose growth chart and bones looked like those of a four-year old. After Diego’s mother revealed that the little boy experienced sexual abuse at four, Burke Harris began to wonder if such events might have a measurable biological effect that drove health disparity rates in Bayview.

Burke Harris has training in public health, and one of the central premises of public health as a discipline is that poverty and poor health outcomes go hand in hand. The statistics on the health disparities between Bayview and that of an affluent neighborhood right beside it bore out this truth; Burke Harris noted that violence—not disease—was the leading cause of death for people in Bayview, unlike in the surrounding, more affluent area.

Burke Harris did see improvement in statistics like vaccination rates because of her clinic’s work but eventually realized after treating many children like Diego that poor health outcomes persisted even with improved access; she was missing something significant in understanding the causes of health disparities. The unfairness of it disturbed her.

As she attempted to puzzle out the link between life in Bayview and poor health even with good access to healthcare, Burke Harris recalled the work of John Snow, a 19th-century doctor. Snow rejected the dominant theory that diseases like plague and cholera (a sometimes-fatal intestinal infection) were spread by bad air (the miasma theory). His rejection of accepted medical wisdom allowed Snow to discover that the bacteria that causes cholera, often found in feces, spread from people’s hands and then to other surfaces and into people’s mouths; this shift in understanding allowed him to predict and stop a cholera outbreak that spread via the contaminated handle of a public well.

After pondering this story, Burke Harris had an insight: Somewhere out there was the equivalent of a well that was the source of poor outcomes for her patients. A decorative frog on the wall of her clinic reminded her of the work of Dr. Tyrone Hayes at University of California, Berkeley—a place where Burke Harris spent a lot of time as a young pre-med student—on how corticosteroids (hormones related to stress) affect the development of tadpoles. Burke Harris suspected that in the case of Diego and children like him, stress was having an effect on their biological processes and thus leading to poorer health outcomes.

Burke Harris returned to her childhood and education to begin solving the puzzle of what was happening to children like Diego. Her father, a renowned Jamaican biochemist who immigrated to the US, taught her that a connection between biochemical processes and natural phenomena exists if you know enough to find it. As a college senior, Burke Harris studied evolutionary biology with the brilliant Black professor Tyrone Hayes, who taught her and his other interns that accidents—experiments that don’t turn out like they should and hypotheses that don’t bear out—are an important part of science if one is attentive.

More specifically, Burke Harris learned during her work in Hayes’s tadpole lab that living creatures strive for homeostasis (a state of balance), and that when stressors throw that balance off, biology allows creatures to adapt to meet those challenges. Tadpoles thrown into a situation that simulates drought and overcrowding release a hormone equivalent to cortisol (the so-called stress hormone in humans), causing their blood pressure and glucose to increase—and causing the resources devoted to growth and reproduction to decrease. Such adaptations help a tadpole deal with stress in its environment more effectively if the tadpole is further along in its development. If the tadpole is early enough in its development, these changes prove maladaptive (bad for survival), and the tadpole never recovers.

Burke Harris considered the results of the tadpole experiments as well as long-established medical knowledge regarding the side effects of high-dose synthetic cortisol in children for whom it is a necessary treatment in some cases. She surmised that evidence of what long-term exposure to stress hormones would do to children already existed. Furthermore, it was common medical knowledge even then that children are much more likely to experience long-term negative effects from hormonal imbalances than adults: The early timing of that exposure made the difference.

Burke Harris suspected that the stress response and the timing of it in children were the biological mechanisms that explained the case of Diego and the health disparities in communities like Bayview. This was a sobering realization but also a hopeful one because it indicated a potential to intervene early to change the outcome.

The final piece of the puzzle about the relationship between ACEs and health disparities came by chance: Burke Harris decided to hire a therapist on the advice of her boss, who told her that because Diego’s hormones tested as normal, talk therapy was the recommended treatment. Using grant funds, Burke Harris hired a therapist who later happened to point her toward a 1998 study, “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: the Adverse Childhood Experiences (ACE) Study,” a journal article in The American Journal of Preventative Medicine by Vincent Felitti, Robert Anda, and others. The study grew out of a chance discovery. Felitti and his co-authors figured out that patients who lost large amounts of weight but dropped out of his seemingly successful obesity clinic were often also survivors of child sexual abuse. This discovery shed light on the relationship between ACEs and poor health outcomes in adulthood. The large study (which included 17,421 predominantly middle-class and white patients in the Kaiser Permanente healthcare system in San Diego) showed that more ACEs correlated with poorer health outcomes even in this affluent group. Burke Harris’s gut instinct was that ACEs explained the same outcomes in the dramatically different Bayview demographic too.

The study was published almost 10 years before Burke Harris was a medical student, and she was shocked that its insights hadn’t been part of her medical and public health education. She speculates that this gap in her education came from an overemphasis on personal responsibility in health outcomes, even though sophisticated research often shows that even people who make healthy choices still suffer worse health outcomes if they had ACEs. Furthermore, ACEs are so widespread that directly confronting them would require acknowledging the sad truth that almost all of us—and most people we know—bear these painful pasts.

Additionally, the study by Felitti et al documented what was happening but not the mechanism for it. Felitti and his colleagues were all but laughed out of conferences, and thus their study never made into Burke Harris’s medical education. Burke Harris believed at the time that if she could show that the stress response was that missing mechanism, she could make a difference in the lives of people burdened by the effect of ACEs.