California’s first surgeon general on Covid: ‘Greatest collective trauma’ of a generation

When Dr Nadine Burke Harris was first appointed California surgeon general, she set out to address the toxic stress and trauma plaguing the state's most vulnerable residents.

Then the pandemic hit. Suddenly, she found herself having to guide millions through statewide shutdowns, and persuade scared, skeptical Californians to get vaccinated against Covid-19 and wear masks to prevent the virus' spread.

Burke Harris, who resigned this month, said the pandemic is "probably the greatest collective trauma of our generation," and she, like all Californians she was sworn to serve - will have a long road ahead processing the last two years.

Reflecting on her three years as surgeon general of the most populous US state, Burke Harris warned that "the health consequences of this pandemic will continue, even after the virus itself is contained."

More than 82,000 Californians have died from the virus, and during Burke Harris' last week the state continued to tally about 200 deaths a day. The state, which was the first to enact stay-at-home orders two years ago, has seen the coronavirus overwhelm hospitals, exacerbate health inequities and disproportionately burden Black and brown Californians.

When Burke Harris was named the state's first-ever surgeon general in January 2019, she stepped into a historic role - one that California governor Gavin Newsom created just for her. Only three other states have surgeon generals. Drawing on her expertise as a pediatrician who specialized in recognizing and treating early childhood trauma, she made it a priority to screen children across the state for signs of extreme stress.

By early 2020, her office had just launched an initiative to train health providers across the state to screen for childhood trauma and abuse and respond with appropriate care. When Covid-19 hit, "everyone had to put a lot of things on pause, to respond to the pandemic", she said. Her office decided they couldn't delay the training program. "Because we're desperately going to need it," she said.

So far, more than 20,000 providers have been trained. Guided by Burke Harris and the surgeon general's office, California also enacted a first-in-the-nation law requiring insurance providers to cover screenings for what pediatric health specialists call "adverse childhood experiences" - including the loss or death of a parent, abuse or neglect - which studies have correlated with a number of chronic health conditions later in life.

Two years into the pandemic, an estimated 200,000 children in the US have lost parents or caregivers. Many more have seen loved ones hospitalized with prolonged illness, or crushed by the stresses of navigating a pandemic with inadequate social safety nets. All that distress, Burke Harris said, will be a heavy burden for children to process - and the state will need to continue investing in helping them do so.

Burke Harris herself will be working to process the past two years. "Serving in a leading public health role during the pandemic," she said, "is almost like a deployment." It required a degree of unwavering focus and dedication. She wasn't able to look away from its horrors, even for a moment. Not even when her mom ended up in the ICU and Burke Harris was unable to see her due to Covid restrictions.

It helped "bring home for me what so many Californians were experiencing, having a loved one in the hospital", she said. "And sometimes you're standing outside. And you can't get in, and you really want to see them - and you don't know how it's gonna go."

During her lowest moment, after she heard former president Donald Trump falsely declare an end to the pandemic in the spring of 2020, Burke Harris allowed herself a few minutes to cry in the restroom.

"And then I came back to work," she said.

Burke Harris' last day was 11 February , and she will use the time off to care for herself and family, she said. Stepping into her role will be the office's chief health officer, Dr Devika Bhushan, who is also a pediatrician with expertise in childhood toxic stress.

For Burke Harris, a doctor and public health expert who had dedicated her career to racial inequities in healthcare, seeing the pandemic immediately exacerbate disparities was "heartbreaking", she said.

"To look and see that some Californians are dying at dramatically higher rates than others - you can know about it, and you can study it, but when you see it and the impact on our communities," she said. "It's absolutely heartbreaking. And incredibly motivating."

In June 2020, as the US erupted in protest against police brutality, Burke Harris wrote in a Medium post: "I often hear the question 'what it is about black and brown people that makes us more vulnerable to the virus? That question infuriates me."

Decades of research show that people's experiences and environments can affect their biology, she continues. "Racist oppression ensures that black and brown children bear a disproportionate burden of dehumanizing and traumatic experiences. Science shows it is sickening them and killing them."

The work of dismantling oppressive systems, and healing the harms they cause is a "continual, ongoing effort", Burke Harris said.

After completing her undergraduate studies at University of California, Berkeley, medical school at University of California, Davis, and earning a master's of public health from Harvard, Burke Harris founded a children's health clinic in San Francisco's Bayview-Hunters Point - a predominantly Black and underserved neighborhood in the city's southeast corner.

Burke Harris had set out to target health disparities in the city, but as she started seeing patients in Bayview she realized many of them needed more than routine physical exams, vaccinations, and prescriptions for inhalers. Many were showing signs of chronic stress, and their bodies were straining under the weight of poverty, societal adversity, and generational trauma.

In 2012, she founded the Center for Youth Wellness, a clinic focused on identifying and treating that sort of stress in children. As surgeon general, Burke Harris made it her goal to bring the services the clinic was providing to children all over the state. One of her proudest moments, she said, was seeing Newsom approve a $4bn investment - made in consultation with her office - in behavioral health screenings and treatment for children and young adults.

"California is leading the nation in our response to the effect that this pandemic has had on kids," she said.

As surgeon general, Burke Harris co-chaired the state's Community Vaccine Advisory Committee, which worked to develop an equitable vaccine distribution plan. "One of my proudest moments when we're looking at the data charting, and we saw the inequities being reduced when it comes to vaccine access," she said.

The disparities haven't disappeared. Vaccinations among Black and Latino Californians continue to lag. As the governor pushes to lift mask mandates in schools across the state, vaccination rates among Black and Latino children are also lagging - fueling concerns that racial and ethnic inequities in coronavirus infections and deaths will be exacerbated in the coming weeks.

"One of the challenges when it comes to addressing inequities is that people think that either you're going to do a program, and that program should fix it. Or you're going to do some kind of one-and-done intervention," she said. "But it requires continual work, continual course correction, continual coordination."