Reimagining Healthcare

Two years ago on a balmy fall evening, after a year of preparation and while the Cubs were still contesting the Dodgers for the League Championship,  Pat Rush, MD, Mardge Cohen MD,  Kathleen Weber, RN MS, and I, along with 80 friends and colleagues from diverse professional and life backgrounds, celebrated the launch of our Center for the Collaborative Study of Trauma, Health Equity and Neurobiology, or THEN. We four women founded this educational program of the Hektoen Institute of Medicine to implement a new approach to two of America’s most complex problems: trauma and health equity.

Who We Are

The four of us had known each other professionally and socially for more than three decades. We began our long relationship while working together at Cook County Hospital, the Chicago area’s only public hospital. We are:

Kathleen Weber, who has studied bio/neurofeedback, mindfulness, structural integration, and Traditional Chinese Medicine;

Mardge Cohen, who (with Kathleen) created integrated and integrative comprehensive healing programs in Chicago and Rwanda for women, children, their partners and families affected by HIV. Both programs have enjoyed impressively high rates of retention; the WE-ACTx Rwanda program was recognized as No. 1 in the country for the number of patients who have achieved viral suppression. Between the two of them, Cohen and Weber have co-authored almost 400 articles in peer-reviewed journals; and

Pat Rush, a “retired” internist and geriatrician, who has been studying and practicing Traditional Chinese Medicine for the last 16 years. She has held positions ranging from associate vice president of an area medical center to solo private practitioner and is currently serving on the School Board in Benton Harbor, Michigan, a majority-minority district fighting hard to survive in spite of opposing financial and political interests.

I am double board-certified in Family and Integrative Medicine and have worked in the public sector for most of my career. I currently work at the intersection of health and education as the medical director of two school health-center programs that provide integrated primary care and behavioral health services to mostly poor Chicago Public School children of color, their families, schools, and communities.

We were motivated to found THEN because our societal health — and health outcomes — have been worsening. The chasm between income and health outcomes for whites and people of color has become much wider rather than closing; the rates of mental suffering, addictions, and suicides have been growing; healthcare costs are rising; and the nation’s physical and mental health lag far behind that of many developed and less developed countries.  The four of us had grown tired of waiting for mainstream healthcare to incorporate modern science, social justice, and ancient wisdom into its teachings, paradigm of care, and practices, and so we struck out on our own and started a nonprofit think tank to push forward our agenda of patient-led, equitable healthcare based on rigorous, cutting-edge evidence.

THEN’s Mission and Goals

THEN’s mission is to create a multidisciplinary community that, by 2025, will develop, disseminate, and implement core curricula that include concepts and practice recommendations regarding trauma, health equity, and neurobiology across the spectrum of all specialties of academic and clinical medicine including psychiatry as well as across all training programs in the health science disciplines.

The core of our work is to use rigorous systems science, the life course perspective, and neurobiology to completely rethink health and disease, both physical and mental:

Systems science is an interdisciplinary field that examines the nature of systems — from simple to complex — in nature, society, and all scientific disciplines with the aim of developing interdisciplinary foundations applicable to diverse fields and sectors.  THEN is applying a systems-science approach to understand and work effectively with human beings and our contexts, health, and healthcare.

Merriam-Webster defines a system as a regularly interacting or interdependent group of items forming a unified whole that is more than the sum of its parts. Systems thinking, a term coined by Barry Richmonds in 1987, allows us to make reliable inferences about the behavior of systems by developing an increasingly deep understanding of their underlying structure and inter-relationships among their components.

The life course is a set of age-dependent developmental trajectories shaped by context. The life-course perspective is a paradigm that uses systems thinking to understand, explain, and improve health and disease patterns across populations. This approach includes observing and acknowledging the complex interplay of biological, behavioral, psychological, social, and historical protective and risk factors that contribute to health outcomes across a person’s lifespan. The life-course perspective emphasizes the importance of time; the timing, patterns, and cumulative impact of all experiences on health; and the existence of critical and sensitive periods of development. Key principles of a life-course approach include the ideas that: health and dis-ease are cumulative and longitudinal, i.e., developed over a lifetime; health and health trajectories are particularly affected during critical/sensitive periods; the broader environment (biologic, social, physical, and economic) affects health and development; and health inequality reflects more than genetics and personal choice ¹. Thus, patterns of health trajectories can be predicted for populations and communities based on individual, social, economic, environmental, and historical exposures and experiences, allowing us to design robust prevention, mitigation, and intervention strategies if and when we pay attention and have the political will.

Finally, neurobiology is the study of the nervous system and the organization of its components into functional circuits ².  These neural networks process and interpret information, delivered via the senses, about experiences from the outside world as well as from inside the body to support overall brain-body physiology.  The nervous system begins to develop in utero and the brain continues to develop throughout childhood, adolescence, and young adulthood in response to experiences ³. The critical period of neurodevelopment between conception and the first few months of life depends on the quality of attachment and attunement with our primary caregiver, which is deeply influenced by the well-being of the mother, her partner, family, and community.⁴.

Equally important to THEN’s work is our commitment to health, health equity, and understanding the historical, social, and structural factors that shape health or illness. The World Health Organization (WHO) defines health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. WHO goes on to describe health equity as a state in which everyone has a fair opportunity to attain their full health potential and that no one is disadvantaged from achieving this potential. Equity implies that avoidable, unfair, or remediable differences among groups of people are absent, whether those groups are defined socially, economically, demographically, geographically or by any other means.⁵.  A large and growing body of research reveals that experiences of discrimination, oppression, poverty, and war literally get under our skin, from conception throughout the life span and from generation to generation, changing our physiology and making us sick. In addition to improving access to healthcare services, understanding and acting on this reality is essential for eliminating health disparities and creating health equity.

THEN’s goal is to create a new paradigm of prevention, diagnosis, and treatment based on these scientific fields/frameworks and on social justice that can transform health professional education, research, and practice to support us in achieving optimal health for all.

Our Perspective

We recognize that the conventional Western classification systems of mental and physical health conditions are based on flawed science shaped by reductionist, hierarchical, and profit-driven ideologies. This approach — the foundation of our failing healthcare system — forces us to see organs, the mind and body, and humans and their environments as separate, disconnected parts operating in isolation. In turn, it clouds our understanding of how health or illness emerges and leads us away from pathways to physical, mental, and social well-being.

This flawed approach perceives us solely as individuals either doomed by our genes or fully responsible for our destiny, uninfluenced by and without influence on our structural, social, and cultural contexts across time.  It imagines that some groups of people have “real” disease and are more deserving of care than others, that health professionals know best and should direct all clinical encounters,  that the physician’s job is to control disease rather support the body’s natural potential to heal, and that our only tools to support health and treat illness are pharmaceuticals, high-tech diagnostic tests, and surgical interventions. This framework has yielded a fragmented, high-cost healthcare system, alienated and dissatisfied patients and clinicians, and poor national health status.

In contrast, we want to create a paradigm built upon the following principles drawn from systems science, the life course perspective, developmental neurobiology, and other evidence-informed studies:

• The brain and body are one interconnected system in dynamic relationship with the complex system of the outside world
• The brain develops in a sequential fashion in the context of relationships and retains the ability to change across the lifespan (neuroplasticity)
• Our experiences, from individual to structural and historical, both protective and adverse, are embodied and shape the development, structure, and function of the brain and its signaling with the body
• The timing and intensity of these experiences matter
• Health or illness is the result of a complex web of events occurring over the life course
• All humans have an innate capacity to be well and to heal
• Humans can help each other heal and stay well through one-on-one relationships and through collective activities within and outside of professional contexts
• All levels of prevention and treatment depend on equitable support of basic needs, development of opportunities for physical and emotional safety, delivery of education and practice of self-regulation and co-regulation activities, and creation of spaces where all people feel a sense of connection and belonging.

Our framework is predicated on our own experiences and on scientific evidence.  We have grown into strong believers, practitioners, and teachers of client-led, client-paced exploration of childhood experiences of all kinds, along with co-development of individualized treatment plans.

This approach is not some “goody two-shoes” idea. Rather, it takes seriously the recognition that the tipping point for physiologic change leading to dis-ease begins in the brain in response to insufficiently buffered adverse client experience prior to presentation. This tipping point may, unfortunately, be hastened and intensified within the context of medical and mental healthcare.  The profound physiologic changes needed to reverse physical or mental illness, therefore, must also start in (and be led by) the client’s brain-body.

Our goals include:

• Promoting collaborative, interdisciplinary learning, innovation, and clinical and basic science research
• Developing a curated and annotated bibliography of high-impact science and popular press articles, books, and other media from related fields
• Sponsoring local journal club/webinars and presentations
• Coordinating interdisciplinary summer student projects and faculty development seminars
• Joining with others to provide translation of science exploring adversity, trauma, resilience, healing, and thriving into personal and community health conversations and actions.

Accomplishments to Date

To begin to build a multidisciplinary community, we created an advisory panel of basic scientists, clinicians, educators, and activists.  With the support of our advisors, we have connected with professionals, students, and activists learning and working in medicine, psychiatry, social work, nursing, psychology, dentistry, pharmacology, public health, child welfare, law, architecture, juvenile justice, faith, community nutrition, yoga, and mindfulness and representing many Chicago-area universities and centers.

To spread the word, we have developed our own approach to presenting complex concepts in a way that is rigorous but understandable to a diverse, cross-sector audience, both professional and community-based. Part of this work has been to create a multi-level curriculum integrating trauma, health equity, neurobiology, and systems science that we plan to disseminate to healthcare training programs of all kinds for use as part of their core curricula.

This past fall, we began piloting the first level of this curriculum with practicing clinicians, educators, and activists, and during the last two years have presented parts of the curriculum to area colleges of medicine, law, and education.

Over this time, we and our advisors have reached more than 8,000 participants through live presentations, online courses, webinars, and podcasts in academic and community spheres.  We have appeared on local and national radio and television and have participated in continuing education, civic engagement, academic and popular writing, and activism.

What’s Next?

We are currently involved in several collaborations with the Child Trauma Academy and with Trauma-Informed Health Care Education and Research (TIHCER), a growing collective of more than 70 physicians, psychiatrists, other clinicians, and researchers from 27 medical schools that are revising training competencies to include a trauma and healing lens with associated skills for U.S. medical students.  We are looking forward to making new connections with other like-minded healthcare professionals, researchers, educators, activists, and community members.

Through TIHCER, we are also participating in a national effort to transform the current American Association of Medical Colleges (AAMC)  “medical student competencies” to include THEN’s core concepts. We will continue connecting knowledge and people to transform the healthcare system into one devoted to, and successful at, true prevention and healing.

THEN’s vision is that by 2025, there will no longer be any need for us. Our hope is that by that time, every health professional training program will have adopted our new paradigm and that every graduate of these programs — along with many faculty, practicing clinicians and basic scientists — will have mastered and been able to apply its core concepts in their work,  allowing us to arrive at a new understanding of the multi-faceted development of disease and how we can best prevent and treat it. Moreover, patients and activists will co-create this paradigm to transform our healthcare system to one that truly serves patients, clinicians, organizations, and the nation and moves us toward the health and well-being that are possible and that we all deserve.

Resources

“New Hope for Chronic Illness” by THEN co-founder Patricia Rush

THEN website

THEN semiannual report 2018

THEN newsletter