Viral Violence and the Challenge for Public Safety


As the screens we carry narrow our proximity to random and targeted acts of violence, many parents and families are rightfully questioning the impact viral violence has on shared perceptions of public safety and child health.

In pediatrics, we have long considered the link between media, violence and health.

We know kids who watch fake violence in movies or play violent characters in video games show signs of increased aggression. But what happens when the violence kids watch is real? Or when the cameraperson is only a teenager?

Today, youth can easily capture and consume real violence, in real-time, as a part of their daily routines – from snapping school violence, live streaming police violence, recording sexual violence, or sharing images of political violence. This is the new normal* and it’s more complex than the simple relationship between simulated exposures and aggression.

A child watching real violence from their cell phone now understands something tangible about the world; and a kid who records or shares violent imagery online can contribute to others understanding of the world. That elevation of the voices and experiences of youth can be extremely valuable. Indeed, in terms of activist’s movements like Black Lives Matter, the perspective of youth, magnified by social media, has become a national catalyst for police reform, criminal justice reform, and racial equity.

Yet, perpetual exposure to viral violence takes its toll – often manifest in feelings of victimization, grief, fear, intimidation, anger and sadness. And kids and teenagers may be most vulnerable to this kind of trauma because they are still developing the emotional and intellectual maturity to process troubling events. What is more, they rely on trusted adult figures to provide safe spaces in their life.

As we face these harrowing challenges, consider two thoughts:

1. While it’s okay to be protective, thoughtful and proactive regarding how youth experience and contribute to violent images online, we, as parents, caregivers, or providers, cannot simply turn a blind eye. While distressing, some images of violence advance our collective understanding, compassion, and empathy for the suffering that exists outside the walls of our private communities or our segregated social groups, and the privileges those spaces confer. In this way, confronting the visual of violence with a particular effort to center the interpretation of the events around the marginalized populations disproportionately affected, is the first step towards collective healing. And that healing begins with rigorous and vigilant public exploration of the ways systemic racism, sexism, Islamophobia, homophobia, xenophobia and intolerance threaten public safety.

2. As we live-stream our lives, we open windows to the neighborhoods we live in, the spaces where our kids learn and play, and the ways we perceive and are perceived in the world. When we don’t like what we see on the other side of that window, it can be easy to hide discomfort or insecurity with blame or shame or to create narratives that distort the humanity we witness. But each time one of us resists the opportunity to understand the burdens or experiences of another, we all move further from the co-existence necessary to bring peace.

*This is a piece I wrote with my friend and colleague, Dr. Wendy Sue Swanson, that was published in the July 2016 Pediatrics. It is available for free online for the first week of publication.

2015: A Year in Review


As many of us begin the time-honored tradition of celebrating what lies ahead, I want to briefly look back and review a year that has meant so much to me. In true New Year’s Eve fashion, I thought a countdown would do the trick.

4. One Degree

For the past year and a half, I’ve coordinated a partnership between our regional American Academy of Pediatrics and One Degree, a SF-based tech non-profit. One Degree and their incredible staff are the brains behind an ambitious project to not just digitize social service referrals, but to do so in a way that strengthens the capacity of the safety net to understand and respond to social needs. By maintaining a platform that is freely available to the public, in English and Spanish, One Degree is also endeavoring to transform referral agencies, from gatekeepers whose staffing capacity determines access to bridges that open access to resource information. They also launched an affordable housing portal this year!

Together, in 2016, we are embarking on a multi-site clinical pilot, to test the feasibility and usability of One Degree’s technology in diverse clinical settings in the Bay Area. We are partnering with a mobile asthma clinic, a clinic for homeless families, a teen clinic, a primary care pediatric clinic, and a free clinic with a large immigrant population. With a team of faculty, providers, and research assistants we hope to refine this technology for use in the clinical setting and broaden the ways healthcare providers address social determinants of health. Here’s a picture of our fearless team!

3. Mentoring

This year, I was fortunate to meet Christine Chen, an inspiring undergraduate student at Stanford University who founded DiverseCity, a website where students “will find the stories advice, and reflections from a diverse range of inspirational people, to show [them] that no matter where [they] come from, or what [their] background, [they] can do incredible things.”

Through Christine’s work, I can hopefully encourage students and trainees to use their voice to make a space at the table for those of us with unconventional interests or underrepresented backgrounds.

To check out Christine’s feature on me, click here and to check out her blog post on Medium, click here. Here are the videos she made:

2. Teaching

In 2015, I had the opportunity to teach 1st and 2nd year Stanford medical students as well residents! When I was a medical student, I was eager to learn about the connections between health and inequality, but early in my education, I found few outlets for my curiosity. Since becoming an attending, introducing medical students to these topics has been a dream of mine. Through the work of students Jessica Steinberg and Brandon Turner, I got to participate in the development and execution of a seminar entitled “Clinical Excellence and Best Practices: Delivering Healthcare to Changing Populations.” This experience was a highlight of the year and something I won’t forget. Here’s my 1st class!

1. Police and Child Health

I, like many who share black skin, have watched, witnessed, black bodies killed without reason or hope for just retribution, by the very agents charged with our protection. And every time, it affects me. Like others, I know the actions of officers in Oakland, Ferguson, New York, Cleveland, Baltimore, Charleston, Chicago, and San Francisco upset more than sensibilities and implicate more than the random carelessness of a select few. It shakes my personal sense of safety and unearths an uncomfortable, non-random reality about being black in America.

But unlike many, whose fear for black lives is more personal than philosophical, I also know the physiology. I know that witnessing violence has important health implications and the impact of police encounters may not be limited to the transience of bruises. For survivors, far more may suffer incarceration, a sustained trauma that separates families, disrupts social networks, and generates new barriers to economic security. I know what is happening to black lives matters, but it isn’t simply an ethical supposition, it’s a biological one.

So I’ve been writing about it, first for my blog, then KQED radio and now Pediatrics (this piece is coming soon!). And I’ve been coordinating a local group of public health leaders, community advocates, and funders to help our public health infrastructure capture and address the health impact of police violence and other harmful police exposures.

More than any work I’ve done this year, this has been the most personal. Addressing social determinants of health is why I became a doctor but elevating the needs and priorities of communities of color within society’s trusted institutions is my life’s work. I feel overwhelming grateful and humbled to begin that work here and now.

Looking back, I never could have guessed the things that happened in 2015 (some that took me away from my blog for months at a time!). Though I hit the highlights here, know it was a year marked by challenges just as much as it was marked by opportunities – lost grants, extended paper revisions, and growing professional relationships. But I made it! I embraced the things that wake me up in the morning and light me up inside and I can’t wait to do it again in 2016.

Happy New Year blog family!

Structural Inequality and the Future of Medicine


4 weeks ago, I published an article on Kevin.MD that garnered a lot of attention. It was titled The Myth of the Entitled Single Mother Remains as Relevant as Ever.* In it, I reversed the popularized notion that single mothers are a societal liability and suggested that instead, they are powerful forces in our local economies and influential leaders of future generations. I presented the idea that how society thinks about single mothers affects how we fiscally prioritize their needs. The point was, stigmatizing public rhetoric informs pubic policy in ways that perpetuate inequality and contribute to poor health. In response, however, I received a number of comments, many from other physicians, suggesting that such a topic was not “medical” enough to warrant physician concern.

That sentiment sits at the crux of one of the most contentious debates in medicine and frames one of the most important questions facing clinicians today. If inequality drives poor health, what is the physician’s role in addressing the structural forces in society that perpetuate inequality?

To answer this question, we must first unpack the ways enduring public narratives inform our institutions and shape opportunities in America. We must talk about how structural forces in society can align to create predictable patterns of disenfranchisement, including inter-generational poverty and poor health. Let’s get started!

The archetypes society erects to distinguish populations, commonly by race, gender, socioeconomic, marital, or immigration status, are not simple social tropes that define broad categorizations of people. Over time, and historically in fact, these social constructs lay deep roots in the political processes that govern society, processes that in turn, inform many of the institutions on which society relies, including the justice system, the education system, and the public health system. This pattern of influence is problematic because it allows shared public stereotypes to drive major public policy. This institutionalizes bias and creates inequality. And as we know, inequality drives poor health.

Let’s take one example of this and flesh it out. Look at the effect of race and gender on incarceration rates in America and the associated health consequences.

African-Americans make up 13.1% of the US population and yet African-American males alone, make up 38% of those incarcerated in federal and state prisons today. That means Black males are 6 times more likely to be incarcerated than White males and if these trends continue, 1 in 3 Black males will be imprisoned at some point in their lifetime.

The origin of the stark racial disparities in the US criminal justice system is complex and multifactorial. It is, in part, related to the disproportionately high rates of poverty,** unemployment, and low educational attainment in African-American communities. But it is also driven by a public narrative that associates Black males with criminality. That is why, even when you control for the crime rate, Black males are more likely to be arrested, once arrested, more likely to be convicted, and once convicted, more likely to face longer prison sentences than their White peers. This criminalization of African-American males is far from benign and, in fact, may have adverse health consequences for Black children and Black families.

When 1 in 3 African-American males are projected to be removed from their communities, often at the age of greatest productivity, it has profound effects on the communities in which these men live.*** Without their earning potential, these families disproportionately rely on the income of single mothers, many of whom live on the brink of poverty.**** Children who live in poverty are more likely to have poor health as adults, including increased risk for cardiovascular disease, high blood pressure, diabetes, arthritis, and depression. What is more, there is evidence to suggest that these risks persist, despite changing social class in adulthood. That means, there are physiologic pathways whereby systems of inequality and social stress may act to create immutable changes to children’s bodies, affecting everything from their brain development to their DNA. These changes can potentially be passed down to future generations, allowing under-resourced social environments to create predictable patterns of disease.

When considered in this way, it is easy to see how shared public narratives can become entangled in policies that systematically disenfranchise families and communities, dismissing productive members of society, shaping local economic opportunities, and informing the health of our future generations. When the life expectancy of a child can be predicted by the zip code in which they live, it exposes important drivers of health and disease in America. As physicians, we must dissect the threads that connect sociopolitical environments to biological consequences. If that is not “medical” enough to warrant our concern, I don’t know what is.

This is the future of medicine and it requires physicians confront issues of stigma and inequality as a function of their clinical duty to promote health and wellness. Doing so will certainly be a challenge. Success will rely on our ability to understand the impact social, political, and economic environments have on the population’s health and, to systematically incorporate this framework into the canon of medical scholarship and medical education. From there, we will need to build interdisciplinary models that bridge political action with health impacts. Jonathan Metzl and Helena Hansen have mapped a way to do that in their article entitled, “Structural Competency: theorizing a new medical engagement with stigma and inequality.” There is much to do be done. Let’s get to work!


* Kevin.MD. is an online medical publication. You can also find this article on my site here!

** Communities in poverty have higher rates of crime regardless of racial composition.

*** This lends a new urgency to addressing the national gender wage gap, a gap that is wider for women of color, as communities of color may disproportionately rely on the income of women. It also underscores the importance of creating pipelines to higher education for men and women of color, to both supplant the pipeline to prison and to position women of color to occupy leadership roles in the community.

**** Many states also legally revoke prior felon’s voting rights and increasingly, laws and policies are being enacted to limit prior felon’s ability to: obtain employment, receive government benefits like food stamps, access public housing, or qualify for student loans. This results in 1 in 13 African-Americans no longer being able to vote today and prevents countless others from making meaningful contributions to their families and communities.