When asked what he sees as the biggest health crisis facing America today, Dr. Robert K. Ross, president and CEO of The California Endowment, has a very different answer from what you might expect. “Five years ago I might have said the obesity epidemic, but a lot of our work focuses on young people and we’ve begun to see that at the root of several chronic diseases plaguing our society is something called toxic stress.”
Toxic stress refers to the trauma many children and young people are exposed to during their formative years through things like domestic violence, neglect, sexual abuse, crime in their community, or the incarceration of a parent. The data show a direct correlation between such stress and life expectancy. “It has a triple whammy effect,” Ross explains. “In the short term kids might act out, be defiant, or be withdrawn. In the medium term they’re at very high risk for juvenile incarceration, substance abuse, and school failure. In the long haul, those same young people are at risk of enduring chronic disease even forty years later.” This phenomenon has long gone unrecognized as a health issue, but Ross and The Endowment believe it is both fixable and treatable.
Addressing large-scale social health issues lies at the very core of what Ross and the Endowment do. Formed in 1996 when Blue Cross converted from nonprofit to for-profit, The California Endowment and its sister foundation, the California Healthcare Foundation, were created to manage the $3B disgorged as part of the Blue Cross transition. The funds were tagged to serve the people of the state of California, and as such, a board of directors reflective of California itself was formed. The board is composed of representatives from different racial backgrounds, genders, and geographical areas. The Endowment’s main goal is to champion and support improved health for underserved and marginalized communities: former gang members, juvenile justice system populations, migrant workers, immigrants, young people with mental health issues, and LGBT communities.
A Structural Approach
Before The Endowment existed, the health philanthropy landscape was fragmented, with each individual group striving to serve only its respective constituents. The formation of The Endowment allowed those groups to connect and collaborate to foment greater societal change – the kind of broad cultural and political shift that seeks to address the roots of a problem, not merely its symptoms.
“Zero tolerance policies in schools became the norm.
We ended up criminalizing a health issue.”
“There are two kinds of philanthropy—charity and change,” says Ross. “Charity is the warm fuzzy kind that the Bible encourages: clothe the homeless, feed the hungry. Change philanthropy, which is what we pursue, focuses on advocacy and systemic change. Why are there so many homeless and hungry people in the first place? What prevention approaches can we support structurally that improve health and wellness?”
This structural cultural approach – and the reality of the struggle – is not new to Ross. As a child raised in a housing project in the south Bronx, he witnessed firsthand what life in a distressed community is like and was inspired to act. “I wanted to play the role of a healer,” he tells us. His zeal to heal and an interest in science led him to pursue a career in medicine.
Ross earned his MD and began working as a pediatrician on the east coast and in Philadelphia. He remembers in particular the crack-cocaine epidemic in the 1990s and the effect it had on the communities he served. “Much of urban America and its black and brown populations were impacted and the policy response was ‘three strikes and you’re out.’ Zero tolerance policies in schools became the norm,” Ross recalls. “We ended up criminalizing a health issue.” He redirected his career toward public health and health policy as he strove to understand the impact these structural and systemic issues had on health. That pursuit led him to join The California Endowment in 2000 where much of his work continues to address things like the school-to-prison pipeline, health insurance access, and toxic stress.
Healthcare for Social Ailments
The issues at hand can be tightly interwoven and require long-term investment to effect change. Take toxic stress, for example: to help a child at risk, the first approach is to invest in early childhood and in training parents to be effective. Parents are a child’s first teachers and having that solid base has an enormous impact.
The next step is to help schools recognize the symptoms of toxic stress as a health issue rather than a disciplinary one, and prepare them to deal with it accordingly. “If a kid acts out or has multiple truancies, chances are these aren’t symptoms of a ‘bad kid,’ but of toxic stress playing out,” Ross notes. “Probably the worst thing you can do is kick the kid out because it further isolates and stigmatizes them.” Instead, schools need access to behavioral health and mental health services, as well as guidance training: for example, a young person who acts out is allowed to stay in school but must also take responsibility for their actions and agree to make it up to the person they offended.
“Hope, optimism, and civic engagement are some of the healthiest
things we can do for each other.”
The third strategy is to focus on helping high-risk populations like children in foster care and young people in the justice system. Rather than have those systems exist as a breeding ground for future inmates, they could be an opportunity to treat trauma and address serious mental health issues at an early stage.
These approaches aren’t theoretical either. The Endowment’s investment in improving school discipline is already bearing fruit: suspensions are down statewide by 30-40% in the last five years. And they haven’t stopped there. In 2010 The Endowment launched Building Healthy Communities, a 10-year, $1B initiative to advance statewide policy, change the narrative around health and social justice, and transform 14 of California’s most devastated communities into places where health and opportunity can thrive.
Ross has reason to believe the improvement will continue. “I don’t see charity cases, I see transformative agents of change. Once a community is engaged, you restore some sense of hope and optimism and they actually become healthier because they begin to care more about themselves and their families. Hope, optimism, and civic engagement are some of the healthiest things we can do for each other.”
Recognizing these issues for what they really are has taken patience and a commitment to active listening to communities and young people. It has required reframing a new narrative of wellness and health for the state.
“We’re having this conversation at a very precarious moment in our nation’s history,” Ross points out. “There’s a lot of racial divisiveness, anxiety and fear, shootings and protests, and the root cause of all that is a lack of compassion and respect and quality, meaningful listening. We’re just not hearing one another well.” But there are those who, like Ross, are willing to stand up and champion those same values: listening, respect, compassion, and advocacy. That is the legacy Ross hopes to inspire.