ICE Cold

Why are you always so political? Don’t you ever shut up about this stuff?

No. Not really. I do not.

Advocacy is both a privilege and, some days at least, an occupational hazard inherent to the practice of pediatrics. When we choose to enter the field of pediatrics, it is something that we sign on for, and typically wholeheartedly and knowingly. As such, most of us operate at the intersection of public health and social justice on a daily basis. It is who we are as pediatricians.

So I’m going to need everybody to temporarily suspend their disbelief and stop acting brand new when you see pediatricians, in particular those that advocate loudly for collective liberation, raising their voices on behalf of children and families. While I would argue that being a person is innately political, especially in our current climate, being a pediatrician has always been political and likely always will be.

As someone who runs a resilience building clinic in one of the largest federally qualified health centers in the country, and as an Angeleno, the recent ICE raids have been deeply gut-wrenchingly disturbing, personally and professionally. My niche is trauma and resilience building, which forces me to confront the layers of complexity and nuance that go beyond simply ripping families apart, which of course should be reason enough for distress.

Now you might be asking yourself why I choose to run a resilience building clinic. Isn’t talking about and/or thinking about trauma a set up for perpetual burnout, moral injury, and compassion fatigue? Perhaps. But as I tell our pediatric residents, when practicing the art of medicine in a sustainable fashion, it’s necessary to examine our “why.” So it’s something that I’ve spent a lot of time thinking about and talking about in recent years. Without forcing you too far down the rabbit hole of research, I will try to be as succinct as my typically verbose self will allow. For starters, we know that adversity and trauma can predispose to a number of health outcomes in adulthood, everything from asthma, obesity, cancer, type two diabetes, mental health issues, cardiovascular disease, autoimmunity, and many more. But we also know that resilience building, especially that which is focused on resources, social determinants of health, and education about lifestyle and facets of resilience (diet, exercise, mindfulness, nature, community, etc) can help mitigate some of these poor health outcomes in adulthood. So simply put, I do what I do because I know that it can help make a difference for my patients long after they walk out of our pediatric clinic for the last time and embark on adulthood.

Helping patients and families build resilience, despite having experienced unspeakable trauma, is one of the most rewarding things I’ve done in my lifetime. But damn if this current dystopia isn’t making it really hard to help people in the setting of a major source of ongoing trauma, ICE raids and the threat of deportation.

And the inconvenient truth of intersectionality, means that adversity does not occur in a vacuum. Unfortunately, it occurs in the milieu of all of the other sources of stress, adversity, and inequity for families. Even putting all that aside and focusing purely on deportation-related trauma, it behooves us to remember that this also occurs against the backdrop of likely migration trauma, which we know is a common phenomenon in our community. Not to mention the trauma and adversity that was likely the impetus for a family fleeing, and/or potentially seeking asylum in the first place. When you then factor in intergenerational trauma, you can see how each layer compounds the baseline toxic stress. Now enter stage right a new(ish) horror, the trauma of ICE raids and subsequent parental estrangement, and the compilation of adverse events is truly dizzying. And unfortunately, these adverse events act in a dose-dependent fashion, increasing even further the likelihood of poor health outcomes in the future. Plus thanks to a phenomenon known as epigenetics, the sequelae of these events can be inherited and passed on for generations to come at the literal DNA level. Why do I feel like I’m filming an infomercial for bonus trauma? “But wait, there’s more…all for the low cost of free ninety-nine.”

Now some of you need no reminder, as you tirelessly raise your voices for collective liberation, heavy on the “collective.” But for everyone else, here is a quick and dirty refresher. We are on stolen land. We exist through the legacy of enslaved people. Apart from indigenous people, we are all either immigrants or descended from immigrants.

If we want to truly embody empathy and fight for equity, it necessitates dismantling systemic oppression. There’s not really a way around that. Unfortunately there is no shortcut here.

Many of the laws governing our carceral system are rooted in white supremacy. ICE is rooted in white supremacy.

Anti-intellectualism/anti-science has always been a tool of white supremacy. They use it because it works. The only way to combat that is with knowledge and data. Likewise, deflection and distraction are age-old tools in the white supremacy tool kit. We must not let them control the narrative, as we’ve seen all too often how it takes on a life of its own, eclipsing the real issues. No doubt you have noticed that burglary is simply regarded as “burglary,” except when it occurs in reasonable proximity to anyone fighting for social justice. Then it is magically “looting.” And as I began to experience again this weekend, Overwhelm is also a tool of white supremacy. It is intentional. But as a very wise colleague reminded me, we can’t let the overwhelm consume us, but rather must focus on what it is that we can control. So as for me, apart from advocating, raising awareness, and droning on about trauma, I can continue helping individual patients and families build resilience. And perhaps if I have any strength left, I can find it within me to continue to hope for an eventual future that does not require so much resilience of people.

Time Travel Jet Lag: Unpacking 4 Different Perspectives

TW: sexual assault, abuse

I am not sure if it was the serious jet lag from twenty-four hours of transit across nine time zones, or the rough reentry and integration back into anything-but-normal life. Or perhaps it was the brutal stripping away of female reproductive rights and the threat of repealing so many other human rights, all whilst ensuring that the leading cause of death in children will continue to be gun violence. Who knows? Could be a combo of all of these. In light of these dystopian gems, plus life in general right now, perhaps it is not surprising that it has taken me a full week to process just the tip of the iceberg of emotion brought on by the events of this past week.

But as a pediatrician whose clinical niches are trauma/adversity, resilience, and equity, as well as children with medical complexity… and as a survivor… it is time to emerge from the brain fog of this past week. Personally and professionally there are so many layers of this to unpack, that it made unpacking the actual luggage from my recent trip seem far less daunting by comparison. And like all unpacking, there is bound to be at least a little dirty laundry.

One of the realities of caring for children with special healthcare needs is that for a certain subset of my patients, a pregnancy could be catastrophic, resulting in death of both my adolescent patient and the fetus. Additionally, my patients with intellectual disability, severe autism, or other neurodevelopmental disabilities are already at higher risk of sexual assault, which is, in and of itself, a terrifying experience for them. Now try to imagine the added horror of becoming pregnant for a patient with limited cognition and/or traditional verbal capacity. My own mind cannot process that fully. Maybe it’s the jet lag.

Furthermore, and please bear with my science nerd perspective for a minute, my work in trauma/adversity, resilience, and equity is aimed at the goals of screening for these factors and helping patients and families build resilience, nurture buffering caregiver/child relationships, and address disparities in social emotional determinants of health (food, housing, transportation, insurance, & other financial or social justice issues). Without going too far down the physiology rabbit hole, adverse childhood experiences (referred to as ACEs), especially when unbuffered and untreated, can lead to chronic activation of the stress response. And that constant “fight or flight,” dynamic can lead to future poor health outcomes such as asthma, obesity, cardiovascular disease, high blood pressure, cancer, depression, anxiety, substance use disorders, and others. As such, childhood adversity poses the single greatest threat to the future health and well-being of our children. To add intergenerational insult to injury, trauma can cause actual changes in the DNA (referred to as epigenetic changes) that can be transmitted to future generations; an ancestral curse in the truest sense. Thus, by forcing a mother to carry an unwanted pregnancy, with its implications for intergenerational poverty and widening disparities, especially within the BIPOC community, our country is actually legislating trauma and adversity for our patients and future generations. I certainly did not order the trauma special with a side of racism, so if you could take it off the menu, that’d be great!

As if all of that is not ominous enough, there are still a few other layers worth unpacking. Please excuse me while I take off my white coat and scrubs for a moment to lend a different, more personal, perspective. In other words, it’s about to get a little more real. When I was in my third trimester with my youngest child, I noticed a small growth at my jawline. Initially thinking it was probably a pimple, and given I was on bed rest, it was convenient to simply ignore it. However, it never really declared itself as a pimple, and it persisted and grew, likely thanks to all those fun pregnancy hormones. It turns out that what I had initially dismissed as a pimple, ended up being a rare tumor (now my second rare tumor…but who’s counting?). I was fortunate that it was at the end of my pregnancy, it was relatively slow growing, and it had not metastasized–a trifecta of oncologic good fortune. Under different circumstances, I could have had an extremely difficult decision to make. It is a decision that no mother should ever have to make, but unfortunately it is all too common amongst cancer survivors. Having begun my cancer journey at age eleven, I am grateful to have lived long enough to have three wonderful children. I cannot imagine if that cancer journey had ended during pregnancy, which is now a very real possibility for so many others.

However, cancer survivorship is not the only meandering journey I have traversed (aka stumbled through) in my life. When it comes to vocations, whether due to comfort or serendipity, sometimes you organically find yourself doing what you know. One reason I have gravitated toward work in adversity and trauma is because I, like many of you, have had a little too much experience doing the hard work of overcoming my own past traumas. While those experiences, and the difficult work of surviving and transcending them, are in the past, there’s nothing quite like having your reproductive rights stripped away to remind you of all you have endured.

By the time I reached double digits, I had been sexually abused, and by the time I reached 20 years of age, I had been raped twice. I was extremely fortunate that I did not end up pregnant, but I cannot begin to imagine how much more difficult my healing journey would have been had I been forced to carry a rapist’s baby. Honestly there are days that I still wonder how I survived abuse, rape, poverty, and cancer to be where I am at today. But then there are other days…days in which the residual sequelae of past trauma are just perceptible enough, at least to me, to remind me that survivorship is a lifelong journey. By the grace of God, the Universe, karma, ancestors, holy water, a lucky penny, and favorable winds, that journey has allowed me to live a life that ensures those past experiences were not in vain. But I can say with reasonable certainty that my ability to not only heal, but to utilize past adversity to ultimately help others, would have been severely impacted by forced pregnancy. So the work of advocacy and activism must be tireless to ensure that every woman has that same chance to not only survive but thrive, despite the intergenerational cycles of trauma and poverty that just became that much harder to break. To that end, it is time to unpack the luggage and get to work, because this jet lag ain’t got nothin’ on time travel back to 1973!

Photo Credit: https://www.zacharyleeportrait.com/

Are We There Yet?

At one time or another, all parents have shared in the universal, yet painful, experience of hearing the words “Are we there yet?” It is typically uttered roughly 379 times, in a shrill, whiny fashion, before we lose it a tiny bit with whichever child cannot help themselves but ask, yet again. So it is in that spirit, that I also dare query whether or not we are there yet. Are we finally through with this discombobulated, chaotic, mass casualty dumpster fire that is 2020? Perhaps not, but like all the countless, persistent children, I cannot help but ask.

Recently I took some time to reflect a bit more on the irony of hosting a conference on adversity and resilience during the most collectively adverse year in either recent or distant memory. For many of my patients and families, as well as many of your own families, 2020 has underscored the acute on chronic nature of adversity and trauma.

Many have experienced job loss, food and housing insecurity, loss of loved ones (and the added grief of knowing some of them passed alone), illness, including COVID, and in some cases, long term sequelae–the aptly-termed “long-haulers.”

In addition, there has been loss of insurance and/or other benefits, lack of access to medical care or understandable fear of accessing care, limited ancillary support services (such as physical or occupational therapy or mental health services), especially those previously provided through schools, and lack of reliable, safe transportation.

Even for those fortunate enough to retain employment, there have been professional hurdles—especially for those working from home while moderating virtual learning, the inherent stress of homeschooling—with its tech/wifi issues and lack of available space, childcare issues for those who cannot work from home, the risk of COVID exposure as essential workers, and the very real fear of becoming ill and/or exposing others.

There are those who, like me, have not seen extended family for nearly a year, those experiencing caregiver fatigue while caring for family members with COVID or chronic illnesses (further exacerbated when trying to limit other in-home caregivers/nurses). Then there is the loss of connection with community, reduced access to green spaces, or risk of COVID while visiting them, the pandemic 15/quarantine 19 (depending upon your level of stress eating), and extreme physical and social isolation.

And while it is unfathomable that we add to this already daunting list, I would be remiss to not highlight the toxic stress manifested in times of political uncertainty, as well as violent conflict in other countries, and the 400 year war of racism that continues to wage in this country.

However, this seemingly exhaustive list of stressors is not meant to overwhelm or cause despair. Though I would be lying were I to say that there aren’t some days in which it does feel overwhelming. Honestly, there are days in which the political, social justice, and medical victories feel overshadowed by hundreds of thousands of lives lost to COVID…overshadowed by the loss of George, Breonna, Ahmaud, and countless others. But for those times when resilience feels almost unattainable and reparations seem to not be actualizable, I hope we can reflect on those who have passed and allow their memory to fuel and energize the fight ahead of us. Because in order to tackle not only the acute, pandemic-related adversity, but dive deeper to address the adversity caused by structural racism and poverty, we will need every bit of that energy.

So rest up and stock up, as masks and vaccines (not toilet paper) will be your ammo in the fight ahead. And while we aren’t there yet, I believe we will get there.

Not so coincidentally…

My closest friends and loved ones know that, even when I haphazardly throw around trite phraseology such “coincidentally,” or “as luck would have it,” that I am being dismissive and inauthentic. Those who love me know that I do not believe in coincidences.

So I do not think it mere coincidence that my youngest child, whose name means “victory,” was born prematurely amidst difficult circumstances, and developed type 1 diabetes as a toddler, celebrated World Diabetes Day during Diwali (the Hindu celebration of victory of light over darkness).

I do not think it is coincidental that during what will surely be touted as one of the most significant, most painful years in our country’s history…a year that has seen unimaginable death, hardship, abject fear, and further widening of disparities that have existed for hundreds of years…that we are finally taking some small steps towards racial equity.

And I do not regard it as coincidence that during the week of an historic election, in which love and equity won by a far narrower margin than many of us would like, that my own professional and personal interests intersected as I hosted a conference on adversity, resilience, trauma, and reparations.

As such, and in the spirit of acknowledging that sometimes God and the Universe are more intentional than I realize, I share with you my opening remarks from the conference.

My name is Dr. Piper Calasanti, and I am a pediatrician at Children’s Hospital Los Angeles. I want to welcome you today to the childhood adversity, resilience, and mindfulness conference, otherwise known as CHARM.

About a year ago, I sat in a large lecture hall with a few hundred of my colleagues, listening to Dr. Nadine Burke Harris, our first California surgeon general, speaking about Adverse Childhood Experiences (ACEs). At the time I was working on editing my manuscript, which is essentially a memoir of my life. Although I had never really thought about my own life in terms of any particular academic verbiage pertaining to trauma, I sat there, staring at her slides and tabulating my own score. As the realization sunk in that I clicked off eight of the original ACEs (out of ten possible), in addition to a few of the other supplemental areas of adversity, it highlighted the importance of two things.

First off, although my score of eight should, statistically speaking, portend some poor health outcomes for me (cardiovascular disease, hypertension, etc.)….aside from being a cancer survivor, I otherwise consider myself to be fairly healthy. Yes I know it’s risky to even put that out there into the Universe. No, I am not intentionally tempting fate. So let’s all just agree to take it as gratitude and illustration that the mere experience of adversity does not always necessarily relegate one to a predestined path.

Now I must absolutely press pause and acknowledge that I had a number of things working in my favor, not the least of which is being white, third generation, speaking English, having some bonded familial relationships, and having a mother who learned to be fairly savvy in terms of navigating services that were available. And despite cultivating, which is a nice way of saying clawing and scraping together, a sense of optimism that has, at times, bordered on pathological, there is no denying the role of those other factors.

Second off, sitting in that room reminded me of the incredible amount of work there is still to be done…individually, professionally, and at a societal level. Now if that isn’t the theme of 2020, as well as the 400 years before that, I don’t know what is.

Four years ago, on election night, I found myself pacing aimlessly through the hospital, not because I was working, but because my youngest child was admitted, having just been diagnosed with diabetes at 20 months of life. I had only recently fully committed myself to the arduous work of breaking intergenerational cycles, and yet now I found myself facing a different hurdle. Watching election results trickle in, I feared the dissolution of all the various health and other related safety nets for my patients and, as a single mom of three, my own family.

While my lived experience, and the lived experience of countless others, highlight the absolute necessity of protecting the personal, familial, community, and societal assets that mitigate toxic stress, there is still an incredible amount of work to accomplish. And while at many moments, just in the last few months alone, that work has felt insurmountable, especially regarding achieving equity, we have to maintain hope that it can, in fact, be actualized.

Some days that hope may be merely a tiny spark, other days we may allow ourselves the luxury of fanning it into a flame.

But it must continue to exist. There is far too much work ahead …. too much tireless advocacy ahead…too much essential activism awaiting us, to let that flame die out. And while some days, or even some weeks, we may need self-care, self compassion, and rest, may it allow us to emerge refreshed and hit the ground running once again.

So in the spirit of taking those first steps, whether you run or walk, I am grateful that all of you have shown up to accompany one another on this journey to build resilience, but also to reimagine a world in which true equity diminishes the need to engineer so much resilience in the first place.

Thank you. Welcome to CHARM. And, in solidarity, let us embark.