This article investigates the impact of trauma on public health and explores strategies for how we can take collective action toward healing.
“One of the clearest lessons from contemporary neuroscience is that our sense of ourselves is anchored in a vital connection with our bodies. We do not truly know ourselves unless we feel and interpret our physical sensations; we need to register and act on these sensations to navigate safely through life. While numbing (or compensatory sensations seeking) may make life tolerable, the price you pay is that you lose awareness of what is going on inside your body and, with that, the sense of being fully, sensually alive.” – Bessel van der Kolk, The Body Keeps the Score
Trauma seems to be on the minds of many today. “Trauma-informed” and “trauma-sensitive” are labels that have been placed onto everything from yoga classes to healthcare to school curricula. But what does trauma truly mean? Why has the popularity of the term begun to soar in recent years? And why does it matter?
What is trauma?
Trauma is by no means a new phenomenon. Violence, war, and other atrocities have been occurring for millennia. Yet with harrowing stories in the media of children fleeing the trauma of violence in their home countries and encountering the trauma of detention centers at the the U.S. border, trauma is a public health issue that has gained international attention in recent months. Moreover, we have only recently obtained scientific evidence to link these events to the debilitating effects of trauma and to show trauma’s devastating impact on public health.
Trauma comes in various forms: For example, collective trauma refers to the effects experienced by a group or society that are encountered from a shared deeply distressing experience, such as armed conflict, genocide, natural disasters, conditions of colonization, or other humanitarian emergencies and that may lead to group identity formation or collective societal changes; on the other hand, individual trauma denotes the individual physical, social, and emotional consequences of traumatic events or circumstances, including witnessing or experiencing domestic violence, sexual abuse, or physical abuse; experiencing parental divorce, separation, substance abuse, mental illness, or incarceration; experiencing emotional neglect or physical deprivation; and experiencing overwhelming grief from loss.
Trauma can be felt across the lifespan, but its most powerful impact is on children. Between the ages of 0-6, children are especially vulnerable to trauma because their brains are rapidly developing. Experiencing toxic stress within this window can cause hyper-arousal of the sympathetic (“fight or flight”) nervous system and disrupt normal brain development. Often, trauma manifests itself as attention deficit hyperactivity disorder (ADHD) symptoms in children and in stress-related disease or cognitive impairment later in life.
Why does trauma matter to public health?
Only recently have medical professionals begun to acknowledge the pervasiveness of trauma in societies throughout the world and its impact on global public health. The Adverse Child Experiences (ACE) study by the Centers for Disease Control and Prevention (CDC) was a major catalyst in this collective awareness. This study, which asked 17,500 (primarily white, college-educated) adults about their experience with childhood trauma, found that over two-thirds of all adults experienced at least one adverse childhood experience before the age of 18. Authors of this study observed another striking finding from these data: they discovered a dose-response relationship between adverse childhood experiences and health outcomes. In other words, experience of childhood trauma was strongly associated with physical and mental health in adults.
Health outcomes that were associated with childhood trauma in the ACE study ranged from chronic obstructive pulmonary lung disease to hepatitis to depression to ischemic heart disease. However, perhaps the most notable association was childhood trauma and suicidality: individuals who had experienced four or more adverse childhood experiences had a relative risk of suicidality 12 times higher than those with zero adverse childhood experiences. Additionally, from this and other studies we know that exposure to childhood trauma in the U.S. is associated with seven of 10 of the leading causes of death, including hypertension and cancer.
Traumatic experiences do not occur at random nationally or globally. Trauma is far more likely to be felt by marginalized communities than by the primarily white, college-educated individuals who participated in the ACE study. Moreover, globally, the experience of trauma is most likely to occur in low and middle-income countries (LMICs). In LMICs and in marginalized communities in the U.S., resources for social services to support healing from trauma may already be limited, making vicious cycles of intergenerational trauma extremely challenging to undo.
In the U.S., the long-term health consequences of trauma have been frequently felt and often studied among veterans who have been diagnosed with post-traumatic stress disorder (PTSD). For veterans and others with this diagnosis, the economic costs of trauma are substantial, leading to an estimated 3.6 days per month of impairment from work compared to those without PTSD. Nationally, the annual cost of productivity lost to PTSD is estimated to be over $3 billion. Yet mental health professionals argue that the diagnosis of PTSD does not adequately capture all those who have experienced trauma. Thus, this estimate for economic loss to trauma is likely to be extremely conservative.
What does a public health approach to trauma look like?
A public health approach to trauma means treating trauma itself rather than (over-)medication of its symptoms (e.g., anxiety, depression, ischemic heart disease, and other associated health outcomes). Trauma prevention should occur within a public health prevention framework, including primary prevention (i.e., to prevent trauma from occurring), secondary prevention (i.e., to intervene early to heal trauma after it has occurred), and tertiary prevention (i.e., to prevent further disability from trauma after it has occurred). An article by Magruder et al. provides an example of a public health prevention framework that includes examples of trauma prevention at each of these levels of prevention at individual, relationship, community, and societal levels (Table 1).
Where does yoga fall into the public health prevention framework?
Trauma awareness has been a popular topic particularly among yoga teachers because of recent evidence of its potential efficacy in healing trauma. Healing is thought to occur at secondary or tertiary individual levels, but yoga may also be arguably effective at a primary preventative level and at a community level.
Psychiatrist Bessel van der Kolk’s book The Body Keeps the Score was one of the catalysts to spark awareness of yoga as a potential treatment for trauma. In his book, van der Kolk argues that many trauma survivors often are out of touch with the experience of being in their bodies because engaging in embodied presence can cause them to be hijacked by survival-related reactions of the sympathetic nervous system. These survival reactions, he says, are often suppressed, yet they are deeply imprinted into the body. Recovery from trauma can be facilitated embodied experiences that allow trauma survivors to learn to self-regulate within a safe environment and to eventually integrate traumatic experience into their personal narratives.
Van der Kolk provides anecdotal evidence in his book for yoga as one such healing embodied experience. Other embodied practices, such as dance, theater, music, and exposure to nature may also show promise to heal trauma. Yet yoga’s potential remains of particular interest to public health communities – perhaps due to the system of philosophy that is embedded into its practice or perhaps due to the cross-pollination of therapists in the field of yoga. Since the book’s publication in 2014, the efficacy of yoga to heal trauma has been a quickly-growing area of research that shows promise for individuals with chronic PTSD and survivors of domestic violence. In the global context, trauma-informed yoga has been found by researchers at Boston University to be feasible and valuable for implementation in Kenya, where it is being used to manage the impacts of traumatic stress.
What are we waiting for?
Given the dire impact of trauma on population health and the potential to use simple, cost-effective measures like yoga to heal and prevent future trauma, it would seem that trauma should be an easy public health problem to solve. But perhaps this hope may be naïve optimism. Progress to create multi-disciplinary treatment teams has been slow. Why? Nadine Burke Harris, a pediatrician and California’s current Surgeon General, suggests that trauma may be an issue too close for comfort for most health professionals to involve themselves in. As she explains to her audience of medical professionals in her TEDMED talk:
“If I were to ask how many people in this room grew up with a family member who suffered from mental illness, I bet a few hands would go up. And then if I were to ask how many folks had a parent who maybe drank too much, or who really believed that if you spare the rod, you spoil the child, I bet a few more hands would go up. Even in this room, this is an issue that touches many of us, and I am beginning to believe that we marginalize the issue because it does apply to us. Maybe it's easier to see in other zip codes because we don't want to look at it. We'd rather be sick.”
Addressing the global burden of trauma on health will undoubtedly require an effort for our leaders to start from within. It’s not until we can fully integrate our own experiences of adversity into our narratives that we can gain comfort in helping others. From the #MeToo movement to the crisis at the U.S. border to the national healthcare crisis that has left millions of Americans uninsured and unprotected from illness, trauma is a public health issue. Yet trauma is also the current story of our humanity – one that must be understood, embraced, and addressed rather than swept under the rug if we want to end its vicious cycle from continuing into the lives of future generations.