How childhood trauma affects health across a lifetime | Nadine Burke Harris | TED

Prevodilac: Ivana Krivokuća Lektor: Ivana Korom

In the mid-'90s,

Sredinom devedesetih,

the CDC and Kaiser Permanente

Centar za kontrolu bolesti (CKB) i "Kaizer Permanente"

discovered an exposure that dramatically increased the risk

su otkrili izlaganje koje drastično povećava rizik

for seven out of 10 of the leading causes of death in the United States.

za sedam od deset vodećih uzroka smrti u Sjedinjenim Državama.

In high doses, it affects brain development,

U velikim dozama, utiče na razvoj mozga,

the immune system, hormonal systems,

imuni sistem, hormonalne sisteme,

and even the way our DNA is read and transcribed.

čak i na način na koji se DNK čita i preslikava.

Folks who are exposed in very high doses

Ljudi koji su izloženi u velikim dozama

have triple the lifetime risk of heart disease and lung cancer

imaju trostruki rizik da obole od bolesti srca i raka pluća

and a 20-year difference in life expectancy.

i razliku od 20 godina očekivane dužine života.

And yet, doctors today are not trained in routine screening or treatment.

A ipak, doktori danas nisu obučeni za rutinsku proveru ili tretman.

Now, the exposure I'm talking about is not a pesticide or a packaging chemical.

Izloženost o kojoj govorim nije pesticid ili hemikalija.

It's childhood trauma.

To je trauma u detinjstvu.

Okay. What kind of trauma am I talking about here?

Okej. O kakvoj traumi govorim?

I'm not talking about failing a test or losing a basketball game.

Ne pričam o padanju na ispitu niti izgubljenoj utakmici košarke.

I am talking about threats that are so severe or pervasive

Govorim o opasnostima koje su toliko ozbiljne ili prožimajuće

that they literally get under our skin and change our physiology:

da nam se bukvalno uvuku pod kožu i menjaju našu fiziologiju,

things like abuse or neglect,

kao što su zlostavljanje i zanemarivanje,

or growing up with a parent who struggles with mental illness

ili odrastanje sa roditeljem koji se bori sa mentalnom bolešću

or substance dependence.

ili bolešću zavisnosti.

Now, for a long time,

Dugo sam ove stvari sagledavala

I viewed these things in the way I was trained to view them,

onako kako sam bila obučena da ih sagledavam,

either as a social problem -- refer to social services --

ili kao društveni problem - koji se tiče socijalnih službi -

or as a mental health problem -- refer to mental health services.

ili kao problem mentalnog zdravlja - upućuje se na službe za mentalno zdravlje.

And then something happened to make me rethink my entire approach.

A onda se dogodilo nešto zbog čega sam preispitala svoj pristup.

When I finished my residency,

Kada sam završila specijalizaciju,

I wanted to go someplace where I felt really needed,

želela sam da odem negde gde sam osećala da sam zaista potrebna,

someplace where I could make a difference.

negde gde mogu da ostvarim promenu.

So I came to work for California Pacific Medical Center,

Tako sam počela da radim za medicinski centar Kalifornija Pacifik

one of the best private hospitals in Northern California,

jednu od najboljih privatnih bolnica u severnoj Kaliforniji,

and together, we opened a clinic in Bayview-Hunters Point,

i zajedno smo otvorili kliniku u Bejvju-Hanters Pointu,

one of the poorest, most underserved neighborhoods in San Francisco.

jednom od najsiromašnijih krajeva u San Francisku.

Now, prior to that point,

Pre toga, postojao je samo jedan pedijatar u celome Bejvjuu

there had been only one pediatrician in all of Bayview

to serve more than 10,000 children,

koji je lečio više od 10 000 dece,

so we hung a shingle, and we were able to provide top-quality care

pa smo mi započeli ovaj posao i mogli smo da pružimo vrhunsku negu

regardless of ability to pay.

bez obzira na nečiju mogućnost da plati.

It was so cool. We targeted the typical health disparities:

Bilo je baš kul. Bili smo usmereni na tipične zdravstvene nejednakosti:

access to care, immunization rates, asthma hospitalization rates,

pristup nezi, stope vakcinisanosti, stope hospitalizacije zbog astme,

and we hit all of our numbers.

i postigli smo sve naše ciljeve.

We felt very proud of ourselves.

Bili smo vrlo ponosni na sebe.

But then I started noticing a disturbing trend.

Ali zatim sam počela da primećujem uznemirujuću tendenciju.

A lot of kids were being referred to me for ADHD,

Mnogo dece mi je bilo upućeno zbog ADHD-a,

or Attention Deficit Hyperactivity Disorder,

poremećaja pažnje sa hiperaktivnošću,

but when I actually did a thorough history and physical,

ali kada sam pregledala njihove kartone i obavila pregled,

what I found was that for most of my patients,

otkrila sam da većini mojih pacijenata

I couldn't make a diagnosis of ADHD.

nisam mogla da dijagnostikujem ADHD.

Most of the kids I was seeing had experienced such severe trauma

Većina dece koju sam primila doživela je tako ozbiljnu traumu,

that it felt like something else was going on.

da se sticao utisak da se tu nešto drugo zbiva.

Somehow I was missing something important.

Nekako mi je promicalo nešto važno.

Now, before I did my residency, I did a master's degree in public health,

Pre specijalizacije, stekla sam diplomu mastera javnog zdravlja

and one of the things that they teach you in public health school

i jedna od stvari kojima uče u školi za javno zdravlje

is that if you're a doctor

je da, ako ste doktor

and you see 100 kids that all drink from the same well,

i vidite da stotinu dece pije sa istog bunara,

and 98 of them develop diarrhea,

i 98 dobije proliv,

you can go ahead and write that prescription

možete da im prepišete antibiotike

for dose after dose after dose of antibiotics,

jednu dozu za drugom,

or you can walk over and say, "What the hell is in this well?"

ili možete da priđete i pitate: "Šta je to u ovom bunaru?"

So I began reading everything that I could get my hands on

Tako sam počela da čitam sve čega sam dokopala

about how exposure to adversity

o tome kako izloženost nepovoljnim uslovima

affects the developing brains and bodies of children.

utiče na mozak u razvoju i tela dece.

And then one day, my colleague walked into my office,

Onda jednog dana, kolega je ušao u moju kancelariju,

and he said, "Dr. Burke, have you seen this?"

i rekao je: "Doktorka Burk, jeste li videli ovo?"

In his hand was a copy of a research study

U ruci je imao kopiju istraživanja

called the Adverse Childhood Experiences Study.

nazvanog Studija nepovoljnih iskustava u detinjstvu.

That day changed my clinical practice and ultimately my career.

Taj dan je promenio moju kliničku praksu i naposletku i moju karijeru.

The Adverse Childhood Experiences Study

Studija nepovoljnih iskustava u detinjstvu

is something that everybody needs to know about.

je nešto što svi treba da znaju.

It was done by Dr. Vince Felitti at Kaiser and Dr. Bob Anda at the CDC,

Obavili su je Dr Vins Feliti na Kajzeru i Dr Bob Anda u CKB-u

and together, they asked 17,500 adults about their history of exposure

i zajednički su pitali 17 500 odraslih za njihovu istoriju izloženosti

to what they called "adverse childhood experiences," or ACEs.

onome što su nazvali "nepovoljna iskustva u detinjstvu" ili NID.

Those include physical, emotional, or sexual abuse;

Oni uključuju fizičko, emocionalno i seksualno zlostavljanje;

physical or emotional neglect;

fizičko i emocionalno zanemarivanje;

roditeljsku mentalnu bolest, bolest zavisnosti, smeštanje u zatvor;

parental mental illness, substance dependence, incarceration;

parental separation or divorce;

razdvojenost roditelja ili razvod;

or domestic violence.

ili nasilje u porodici.

For every yes, you would get a point on your ACE score.

Za svako da se dobija poen na NID skali.

And then what they did

A zatim su korelirali te NID rezultate sa zdravstvenim posledicama.

was they correlated these ACE scores against health outcomes.

What they found was striking.

Ono što su otkrili je zapanjujuće.

Two things:

Dve stvari:

Number one, ACEs are incredibly common.

Prvo, NID su neverovatno česta.

Sixty-seven percent of the population had at least one ACE,

67 posto populacije je imalo bar jedno NID,

and 12.6 percent, one in eight, had four or more ACEs.

i 12,6 posto, jedan od osam, imalo je četiri ili više NID.

The second thing that they found

Druga stvar koju su otkrili

was that there was a dose-response relationship

je da postoji odnos doze i reakcije

between ACEs and health outcomes:

između NID i zdravstvenih posledica:

the higher your ACE score, the worse your health outcomes.

što je viši vaš NID rezultat, gore su vam zdravstvene posledice.

For a person with an ACE score of four or more,

Za osobu sa NID rezultatom od četiri ili više,

their relative risk of chronic obstructive pulmonary disease

rizik od hronične opstruktivne plućne bolesti

was two and a half times that of someone with an ACE score of zero.

je dva i po puta veći u odnosu na nekog sa NID rezultatom od nula.

For hepatitis, it was also two and a half times.

Za hepatitis, rizik je takođe dva i po puta veći.

For depression, it was four and a half times.

Za depresiju, četiri i po puta.

For suicidality, it was 12 times.

Za sklonost samoubistvu, 12 puta.

A person with an ACE score of seven or more

Osoba sa NID rezultatom od sedam ili više

had triple the lifetime risk of lung cancer

ima trostruku šansu da dobije rak pluća

and three and a half times the risk of ischemic heart disease,

i tri i po puta veći rizik od ishemijske bolesti srca,

the number one killer in the United States of America.

ubice broj jedan u Sjedinjenim Državama.

Well, of course this makes sense.

Naravno da ovo ima smisla.

Some people looked at this data and they said, "Come on.

Neki ljudi su pogledali ove podatke i rekli: "Ma dajte.

You have a rough childhood, you're more likely to drink and smoke

Kad imate teško detinjstvo, verovatnije je da ćete da pijete i pušite

and do all these things that are going to ruin your health.

i radite sve te stvari koje će vam uništiti zdravlje.

This isn't science. This is just bad behavior."

To nije nauka. To je samo loše ponašanje."

It turns out this is exactly where the science comes in.

Ispostavilo se da upravo tu nauka dolazi do izražaja.

We now understand better than we ever have before

Sada razumemo bolje nego ikada pre

how exposure to early adversity

kako izloženost ranim nedaćama

affects the developing brains and bodies of children.

utiče na mozak u razvoju i tela dece.

It affects areas like the nucleus accumbens,

Deluje na oblasti kao što je nukleus akumbens,

the pleasure and reward center of the brain

centar mozga za zadovoljstvo i nagrađivanje

that is implicated in substance dependence.

koji je uključen kod bolesti zavisnosti.

It inhibits the prefrontal cortex,

On inhibira prefrontalni korteks,

which is necessary for impulse control and executive function,

koji je neophodan za kontrolu impulsa i izvršnu funkciju,

a critical area for learning.

ključna oblast za učenje.

And on MRI scans,

I na MRI skeniranju

we see measurable differences in the amygdala,

vidimo merljive razlike u amigdali,

the brain's fear response center.

centru mozga za reakciju straha.

So there are real neurologic reasons

Dakle postoje stvarni neurološki razlozi

why folks exposed to high doses of adversity

zašto su ljudi izloženi brojnim nepovoljnim okolnostima

are more likely to engage in high-risk behavior,

skloniji visoko rizičnom ponašanju,

and that's important to know.

i to je važno znati.

But it turns out that even if you don't engage in any high-risk behavior,

Ali ispostavilo se da čak i ako ne ispoljavate visoko rizično ponašanje,

you're still more likely to develop heart disease or cancer.

još uvek imate veću šansu za nastanak bolesti srca ili rak.

The reason for this has to do with the hypothalamic–pituitary–adrenal axis,

Razlog tome ima veze sa hipotalamičko-hipofizno-adrenalnom osom,

the brain's and body's stress response system

moždanim i telesnim sistemom za reagovanje na stres

that governs our fight-or-flight response.

koji upravlja našim odgovorom "bori se ili beži".

How does it work?

Kako to funkcioniše?

Well, imagine you're walking in the forest and you see a bear.

Zamislite da šetate šumom i vidite medveda.

Immediately, your hypothalamus sends a signal to your pituitary,

Istog trenutka, vaš hipotalamus šalje signal hipofizi,

which sends a signal to your adrenal gland that says,

koja šalje signal nadbubrežnoj žlezdi koja kaže:

"Release stress hormones! Adrenaline! Cortisol!"

"Otpustite hormone stresa! Adrenalin! Kortizol!"

And so your heart starts to pound,

Tako vaše srce počinje da lupa,

Your pupils dilate, your airways open up,

vaše zenice se šire, disajni putevi se otvaraju,

and you are ready to either fight that bear or run from the bear.

i spremni ste da se borite sa medvedom ili da bežite od njega.

And that is wonderful

I to je sjajno

if you're in a forest and there's a bear.

kada ste u šumi i tu je medved.

(Laughter)

(Smeh)

But the problem is what happens when the bear comes home every night,

Ali problem je šta se desi kada medved dolazi kući svake noći,

and this system is activated over and over and over again,

i ovaj sistem se aktivira iznova i iznova i iznova,

and it goes from being adaptive, or life-saving,

i pretvara se od adaptivnog ili spasonosnog

to maladaptive, or health-damaging.

u maladaptivni ili štetan po zdravlje.

Children are especially sensitive to this repeated stress activation,

Deca su naročito osetljiva na tu ponavljanu aktivaciju stresa,

because their brains and bodies are just developing.

jer se njihov mozak i telo tek razvijaju.

High doses of adversity not only affect brain structure and function,

Mnogo nepovoljnih okolnosti ne samo da utiče na strukturu i funkciju mozga,

they affect the developing immune system,

utiču na imuni sistem u razvoju,

developing hormonal systems,

hormonalne sisteme u razvoju,

and even the way our DNA is read and transcribed.

čak i na način na koji se DNK čita i preslikava.

So for me, this information threw my old training out the window,

Za mene je ovaj podatak odbacio moju staru obuku,

because when we understand the mechanism of a disease,

jer kada razumemo mehanizam bolesti,

when we know not only which pathways are disrupted, but how,

kada znamo ne samo koji putevi su prekinuti, već i kako,

then as doctors, it is our job to use this science

onda je nama kao doktorima zadatak da koristimo nauku

for prevention and treatment.

radi prevencije i tretmana.

That's what we do.

To je ono što mi radimo.

So in San Francisco, we created the Center for Youth Wellness

U San Francisku smo osnovali Centar za dobrobit mladih

to prevent, screen and heal the impacts of ACEs and toxic stress.

da bismo predupredili, pregledali i zalečili uticaje NID i toksičnog stresa.

We started simply with routine screening of every one of our kids

Počeli smo prosto rutinskim pregledom svakog našeg deteta

at their regular physical,

na njihovom redovnom sistematskom,

because I know that if my patient has an ACE score of 4,

jer znam da ako moj pacijent ima NID rezultat od 4,

she's two and a half times as likely to develop hepatitis or COPD,

ima dva i po puta veću šansu da dobije hepatitis ili HOPB,

she's four and half times as likely to become depressed,

četiri i po puta veću šansu da postane depresivan,

and she's 12 times as likely to attempt to take her own life

i 12 puta veću šansu da pokuša da oduzme sebi život

as my patient with zero ACEs.

u odnosu na pacijenta sa nula NID.

I know that when she's in my exam room.

To znam kada se nalazi u mojoj sobi za preglede.

For our patients who do screen positive,

Za naše pacijente koji se pokažu kao pozitivni na pregledu,

we have a multidisciplinary treatment team that works to reduce the dose of adversity

imamo multidisciplinarni tim za tretman koji radi na smanjenju nepovoljnosti

and treat symptoms using best practices, including home visits, care coordination,

i leči simptome koristeći najbolju praksu, uključujući kućne posete,

koordinaciju nege, negu mentalnog zdravlja, ishranu,

mental health care, nutrition,

holističke intervencije, i da, primenu lekova kada je to neophodno.

holistic interventions, and yes, medication when necessary.

But we also educate parents about the impacts of ACEs and toxic stress

Ali takođe edukujemo roditelje o uticaju NID i toksičnog stresa

the same way you would for covering electrical outlets, or lead poisoning,

na isti način na koji bismo to činili

kada se radi o pokrivanju utičnica ili trovanju olovom

and we tailor the care of our asthmatics and our diabetics

i oblikujemo negu za naše astmatičare i dijabetičare

in a way that recognizes that they may need more aggressive treatment,

na način koji prepoznaje da im je možda potreban agresivniji tretman,

given the changes to their hormonal and immune systems.

uzevši u obzir njihov hormonalni i imuni sistem.

So the other thing that happens when you understand this science

Druga stvar koja se desi kada razumete ovu nauku

is that you want to shout it from the rooftops,

jeste to da želite da je razglasite na sva zvona,

because this isn't just an issue for kids in Bayview.

jer to nije samo problem dece u Bejvjuu.

I figured the minute that everybody else heard about this,

Pretpostavila sam da onog trenutka kada svi ostali čuju za ovo,

it would be routine screening, multi-disciplinary treatment teams,

to će biti rutinski pregled, timsko multidisciplinarno lečenje,

and it would be a race to the most effective clinical treatment protocols.

da će se takmičiti ko će imati najefikasnije kliničke protokole lečenja.

Yeah. That did not happen.

Kako da ne. To se nije dogodilo.

And that was a huge learning for me.

To je bila velika stvar koju sam naučila.

What I had thought of as simply best clinical practice

Ono što sam smatrala jednostavno najboljom kliničkom praksom

I now understand to be a movement.

sada shvatam da je pokret.

In the words of Dr. Robert Block,

Rečima Dr. Roberta Bloka,

the former President of the American Academy of Pediatrics,

bivšeg predsednika Američke akademije pedijatara:

"Adverse childhood experiences

"Nepovoljna iskustva u detinjstvu

are the single greatest unaddressed public health threat

su najveća nerazmotrena opasnost po javno zdravlje

facing our nation today."

sa kojom se naša zemlja danas suočava."

And for a lot of people, that's a terrifying prospect.

Za mnoge, ovo su užasavajući izgledi.

The scope and scale of the problem seems so large that it feels overwhelming

Obim i razmere problema deluju tako veliko da se čini nesavladivo

to think about how we might approach it.

razmišljati o tome kako da mu pristupimo.

But for me, that's actually where the hopes lies,

Ali za mene, upravo tu leži nada,

because when we have the right framework,

jer kada imamo pravi okvir,

when we recognize this to be a public health crisis,

kada prepoznamo da je ovo kriza u javnom zdravlju,

then we can begin to use the right tool kit to come up with solutions.

tada možemo početi da koristimo pravi alat da dođemo do rešenja.

From tobacco to lead poisoning to HIV/AIDS,

Od duvana i trovanja olovom do side,

the United States actually has quite a strong track record

Sjedinjene Države zapravo imaju prilično jake rezultate

with addressing public health problems,

u rešavanju problema javnog zdravlja,

but replicating those successes with ACEs and toxic stress

ali za ponavljanje tih uspeha sa NID i toksičnim stresom

is going to take determination and commitment,

biće potrebna odlučnost i posvećenost,

and when I look at what our nation's response has been so far,

i kada pogledam na to kakav je odgovor naše zemlje bio do sada,

I wonder,

pitam se,

why haven't we taken this more seriously?

zašto ovo nismo uzeli ozbiljnije?

You know, at first I thought that we marginalized the issue

Znate, prvo sam pomislila da smo marginalizovali ovaj problem

because it doesn't apply to us.

jer se ne odnosi na nas.

That's an issue for those kids in those neighborhoods.

To je problem one tamo dece u onim tamo krajevima.

Which is weird, because the data doesn't bear that out.

Što je čudno, jer podaci to ne pokazuju.

The original ACEs study was done in a population

Izvorno NID istraživanje je obavljeno u populaciji

that was 70 percent Caucasian,

koja je bila 70 posto bele rase.

70 percent college-educated.

70 posto fakultetski obrazovanih.

But then, the more I talked to folks,

Ali onda, što sam više pričala sa ljudima,

I'm beginning to think that maybe I had it completely backwards.

počela sam da pomišljam da sam možda sve naopako shvatila.

If I were to ask how many people in this room

Kada bih pitala koliko je ljudi u ovoj prostoriji

odraslo sa članom porodice koji je patio od mentalne bolesti,

grew up with a family member who suffered from mental illness,

I bet a few hands would go up.

kladim se da bi se nekoliko ruku podiglo.

And then if I were to ask how many folks had a parent who maybe drank too much,

A ako bih pitala koliko je vas imalo roditelja koji je možda previše pio,

or who really believed that if you spare the rod, you spoil the child,

ili koji je zaista verovao da je batina iz raja izašla,

I bet a few more hands would go up.

kladim se da bi se još nekoliko ruku podiglo.

Even in this room, this is an issue that touches many of us,

Čak i u ovoj prostoriji, to je pitanje koje se tiče mnogih od nas,

and I am beginning to believe that we marginalize the issue

pa počinjem da verujem da marginalizujemo problem

because it does apply to us.

jer se odnosi na nas.

Maybe it's easier to see in other zip codes

Možda ga je lakše videti sa udaljenosti

because we don't want to look at it.

jer ne želimo da ga sagledamo.

We'd rather be sick.

Radije bismo bolovali.

Fortunately, scientific advances and, frankly, economic realities

Srećom, napredak nauke i, iskreno govoreći, ekonomska stvarnost

make that option less viable every day.

svakim danom čine tu opciju manje održivom.

The science is clear:

Nauka je jasna:

Early adversity dramatically affects health across a lifetime.

rane nepovoljne okolnosti drastično utiču na zdravlje tokom života.

Today, we are beginning to understand how to interrupt the progression

Danas počinjemo da razumemo kako da prekinemo širenje niza

from early adversity to disease and early death,

od ranih nepogodnosti do bolesti i preuranjene smrti,

and 30 years from now,

i za 30 godina,

the child who has a high ACE score

dete koje ima visok NID rezultat

and whose behavioral symptoms go unrecognized,

i čiji simptomi u ponašanju nisu prepoznati,

whose asthma management is not connected,

čija kontrola astme je nepovezana,

and who goes on to develop high blood pressure

i koje razvije visok krvni pritisak

and early heart disease or cancer

i rano srčano oboljenje ili rak

will be just as anomalous as a six-month mortality from HIV/AIDS.

biće podjednako neuobičajeno kao šestomesečna smrtnost od side.

People will look at that situation and say, "What the heck happened there?"

Ljudi će videti tu situaciju i reći: "Šta se, dođavola, ovde dogodilo?"

This is treatable.

Ovo je moguće lečiti.

This is beatable.

Ovo je moguće pobediti.

The single most important thing that we need today

Najvažnija stvar koja nam je potrebna danas

is the courage to look this problem in the face

jeste hrabrost da gledamo ovom problemu u lice

and say, this is real and this is all of us.

i kažemo, ovo je stvarno i ovo smo svi mi.

I believe that we are the movement.

Ja verujem da smo mi pokret.

Thank you.

Hvala.

(Applause)

(Aplauz)