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.

Chasing Sunsets

I recently celebrated a birthday and must admit I always find birthdays a little bittersweet. When I was in my twenties (and for a moment we’ll pretend that wasn’t so long ago), I used to regard that bittersweetness as the result of a remote traumatic experience that occurred on my birthday. But having done the work of healing, and as I got older, I recognized the sentiment was rooted in something seemingly deeper, yet in a way, much simpler. It is somewhat analogous to a sunset which, while beautiful, still represents an end. A birthday signals an opportunity to reflect on where I have been, who I have been, what I have accomplished, and how far I still have to go. What will that next sunrise look like? It’s a chance to be grateful for the tremendous things I have overcome in my life, as well as for the amazing friends who have accompanied me on this journey. It’s a chance to revel in the memories and experiences of the last year(s)…every beautiful sunset…while still acknowledging the occurrences of trauma, loss, or pain that can punctuate any number of the preceding 365 days.

Like many of you, I am no stranger to the fact that pain, change, and loss, despite being part of life and God’s plan, can be hard as hell sometimes. Recognizing how far we have to go individually, and how much work we need to do as a loving, empathetic, selfless society, can feel overwhelming. And even the most eager to attain growth and progression…those ready to advocate for themselves and others…can sometimes feel as if they are standing still.

Those bittersweet moments of taking stock require a tremendous amount of grace and love, not to mention an insane dose of patience (often in short supply). I have always clung to the notion that most things happen for a reason, according to a plan for which, ironically, none of us has the blueprints. That said, I think we can all agree that sometimes things happen that are so difficult, painful, unexpected, seemingly senseless, that it’s hard to imagine there could ever be a reason that could do it justice. Is there always a lesson in death, war, violence, and loss? However, I suppose these are occupational hazards of operating in a world with free will…which admittedly feels like a fancier version of “it is what it is.” Yet it is also that same free will that allows us to make choices that hopefully, if we choose wisely, allow us to live in authenticity and love.

So for this next year the best gift I can give myself is for my actions and inactions to continue to reflect and foster the life I am building for myself and my children, and I pray for grace and love throughout this next trip around the sun. May God grant that the less palatable, painful moments be tempered with an abundance of sweetness and some beautiful views of the sun.

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/

An Open Letter to my Children

At the end of one of the busiest weeks I have had in recent memory….a week for which there is no adequate word in the English language and “insane” cannot begin to do justice…I paused. There were a number of reasons to pause at that moment, but the reason I chose was that I owed my center offspring a conversation. As we spoke, I told him how proud I was of something he had recently done, but he stopped me mid-sentence. “Mom I know.” I tried to continue, tried to tell him that I am always proud and why I hold him to such a high standard. But he stopped me again. “ Mom (more emphatically)…I know! I literally have the letter you wrote me on my birthday here on my desk.”

Later I reread that letter (which is conveniently my blog entry from a year ago) and mused to a few friends that maybe I should take my own advice. Suddenly, I remembered that I had penned the beginnings of a letter to all three of my kids but had never quite completed it. And just like that, the Universe had spoken. In a week filled with deadlines, check boxes, and turning pages, it was time to finish what I had started.

An open letter to my children…

First off, I must acknowledge that I know that you will not heed all of this advice. As your mother I fully expect you to ignore many of these suggestions, the same way in which you ignore the first six times I ask you to do pretty much anything. But joking/parental snark aside, some things you will simply need to learn on your own. And that is OK. My hope is that if you must experience some things firsthand, perhaps the knowledge gleaned will endure within you. That said, it is perfectly acceptable to need to learn and re-learn these lessons. You will backslide. That is also OK. Be gentle and patient with yourself. As long as you honor your authenticity, continue being a good person, and your overall trajectory is forward, that is what matters most.

1. I am proud of you, and I will always love you… beyond measure, no matter what. If you know nothing else, know this.

2. You are now and will ALWAYS be enough. Always be yourself. If someone does not appreciate who you are as a person, they do not belong in your life. Period. This does not mean that you shouldn’t strive for personal improvement or embrace needed changes throughout life. What you do not change, you choose. But such changes must be congruent with your core values.

3. Your worth will NEVER be diminished by someone else’s inability to see it. Do not waste your time trying to prove your worth to someone who is incapable of seeing it. Run, do not walk, away.

4. Be honest and transparent ALWAYS. There is never an excuse for lying. Integrity is everything. It really is that simple.

5. Action always expresses priority (I remain eternally grateful to Gandhi for the reminder). Make sure your actions align with your words. And never forget that inaction can be as powerful a choice as action. So choose wisely.

6. Be very mindful of how you spend your time, energy, and effort. You have the power to cultivate the life you choose.

7. NEVER diminish yourself to make someone else feel comfortable. If you are “too much” for someone, walk away and let them settle for less. You are not meant to be diluted.

8. Sometimes doing the right thing will be among the hardest things you will ever do. The path of least resistance is very often the wrong path. Choose the other path….that’s your path…and put in the work, even when it’s difficult.

9. Never forget who you are or where you came from. Let the things that you have transcended form your foundational core. And never forget to leverage your place in this world to help others.

10. Happiness comes from within. You, yourself, are solely responsible for being happy. And it is never your responsibility to curate happiness for another person.

11. Even on your hardest days, and even when pain and tears feel unceasing, there is always a reason to be grateful. Always. Gratitude is absolutely essential. Do not underestimate its power.

12. Embrace the fact that individuality means you may not always agree on everything with friends and loved ones. Our world would be quite boring if we all agreed all the time. Be willing to keep respectful dialogue open, but recognize it is OK to “agree to disagree.” One caveat—this advice does NOT apply to racism, misogyny, homophobia, xenophobia, etc.

13. Always be willing to consider the perspective and viewpoints of another person or group. Again, you do not have to agree, but be willing to “hear,” and consider the thoughts of the other person/group, as long as it is presented respectfully. The caveat from #12 above applies here as well.

14. Never ever be afraid to express your feelings or opinions (preferably in a respectful manner, of course). You are as equally deserving of the opportunity to be heard as anyone else in your life. Dispense with people who consistently dismiss or invalidate your feelings or opinions. This takes practice throughout your life. A lot of practice.

15. Do not ever apologize for feeling a particular feeling. Own it, embrace it, learn from it. What does that feeling tell you about life, yourself, another person, thing, event? Some feelings are transient and require nothing more than feeling them and moving on. Other feelings are more persistent and may signify a more important issue worthy of your attention. It will take a lot of practice to distinguish between the two, but it is necessary.

16. Do not ignore or suppress your thoughts or feelings. It is not healthy, and no good will come from doing so. Brief denial, in the setting of trauma or loss, is completely normal. Have patience with a little denial from time to time, but do not set up shop there. You CANNOT cheat grief, hurt, or loss. It will come back like a boomerang every time. Deal with it so you can move on.

17. Humility is essential. No one is perfect. Everyone makes mistakes in life, and you will make more than you ever dreamed. That’s actually OK…it’s part of learning and growing. But you must be willing to admit your mistakes and be accountable. Progress toward a solution even if it means constantly holding yourself accountable. Try to break cycles (both personal and intergenerational). But also show yourself compassion and patience when you falter. And you will falter.

18. No matter how smart you are or how much education you have, there will always be things beyond the scope of your knowledge. There is no shame in saying “I don’t know the answer.” Likewise there is no shame in asking for help. Stay humble. It may be the very thing that saves you or someone else.

19. When you face trauma, you have two choices. You can choose to do the work to survive, thrive, and transcend….to allow it to become part of your story and make you stronger than you ever dreamed. Or you can choose to let it destroy you, defining you in a way that hinders your potential and can leave a wake of destruction along the way. My prayer is that you ALWAYS choose to do the work and transcend anything that life throws at you. In the moment that may feel like the harder choice, but choosing resilience will always be worth it.

20. Show empathy whenever possible. Being an empath will absolutely make you an easy target for some people. Do it anyway. And in the event that showing empathy threatens your own health and well-being, peacefully detach and honor yourself, saving your empathy for a more deserving circumstance.

21. Unfortunately, you will be hurt very deeply more than once in your life. But do not ever let it break you nor dim your light. The one thing that no one can EVER take from you is who you are at your core. Continue shining and being the amazing person you already are. Wake up each day and leverage the gifts God has given you to keep helping others.

22. There will be dishonest, cruel, selfish people in this world. But there are many truly amazing people out there as well. And while it can be difficult to tell the difference between the two at times, be willing to be vulnerable and trust others. I know it’s risky, and yes it means some inevitable pain. Just know that it will be worth it someday. However, once someone shows you who they really are, believe them. Let God, Universe, and karma sort the rest out.

23. Learn, and when necessary, relearn to trust your intuition. Let it be the powerful guide that God/Universe intended. When you feel yourself trying to justify ignoring it, take a step back and recenter. Then trust yourself, even if it means accepting something difficult or painful.

24. True, real love is unconditional. Your presence, however, is conditional. You teach others how to treat you based upon what you allow. Never condition others to take you for granted. Walk away and go where you are cherished.

25. When you inevitably find yourself in the heartbreaking situation in which your love, priority, effort, and support are not reciprocated, please leave. Love yourself more in that moment, walk away, and do not look back. Your direction is forward.

26. Although you will have your heart broken in life, love anyway. Love anyway. It would be a far bigger shame to never take that chance. Love hard and unapologetically.

27. And if all else fails, please see #1

Love always,

Mom

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.