Gabriel Kaplan Comments

In this issue of AJPH, the editorial by Atchison et al. (p. 450) reminds readers that any consideration of the social determinants of health must make room for strategies to address, prevent, and reverse the lingering health effects that can result from adverse childhood experiences (ACEs).¹ Atchison et al. highlight a clinical–community partnership in Iowa between clinicians, educators, and others to do this, but they note the many challenges of governance and infrastructure identified by this initiative. Such challenges should remind AJPH readers of the need to center public health within any attempt to redress deep-seated social problems that would otherwise increase disease prevalence and translate socioeconomic inequities into health disparities.

This editorial has numerous good ideas, and at a time when large segments of the public health community have shown an understanding of the social determinants of health concepts and seem persuaded of their importance, the authors provide the elements of a roadmap regarding how public health can address factors that lead to poor health outcomes with respect to one key upstream factor: ACEs. This is long overdue, because a significant demand exists across the field for instruction on incorporating this work into current practice.² Any attempt to follow Atchison et al.’s guidance, however, should integrate several additional points.

Public health organizations are more than just one component of clinical–community partnerships as suggested in the editorial by Atchison et al. The Iowa example highlighted the need to solve key problems of governance and infrastructure, particularly as they relate to data security and privacy. In many states, governmental public health has the legal status to safeguard privacy and also to gather and analyze private health data that many other organizations cannot. It is well poised to play a key convening role in community-based partnerships that marry the health sector to other social service–oriented organizations.^3,4

Public health also has a key advocacy and educational role to play in preventing and mitigating exposure to ACEs. Multiple studies have shown that ACEs such as abuse, neglect, and household dysfunction are correlated with poorer health outcomes, but they are not entirely determinative of them either.⁵ Research shows examples of individuals with high ACEs scores who do remarkably well. Protective factors that increase individual resilience, such as having a caring adult in one’s life or developing life skills to cope with setbacks and conflict, help many individuals overcome multiple traumatic and challenging experiences. Much of what is described as neglect in this framework results not from parental indifference but from substantial socioeconomic challenges facing the adults in the household. Although the clinical sector will be a key partner in helping to identify individuals who experienced ACEs and providing support and care to aid recovery, public health must coordinate comprehensive, evidence-based, population-level preventive measures that transform the environment by addressing community safety, poverty, and discrimination and that strengthen families by deploying programs that build caregiver skills or foster more nurturing educational environments to support positive child and youth development.

A key risk within the current fascination so many have for work on the social determinants of health is that public health gets bypassed altogether in favor of partnerships between the social sector and clinicians or the education sector and clinicians or that social problems become medicalized by the creation of screening and referral mechanisms within clinical settings. The social determinants of health framework calls for us to consider the relation between macrolevel factors such as poverty, inequality, and discrimination; mesolevel factors such as the levels of economic opportunity in a community, access to safe places to play, and exposure to crime and violence; and microlevel factors such as family dysfunction, allostatic load, and educational experiences. Clinical–community partnerships can operate at all three levels. Primarily, they are more microlevel oriented. But public health can convene local physicians to get involved in meso-community-oriented strategies and to advocate and lobby policymakers for more macrolevel interventions. Only a multilevel approach to these problems will be sufficient to hold back the repeated assaults they can inflict on individual efforts to stay healthy. Only public health is poised to coordinate across these levels and convene partners to direct responses toward problems at each level.