Interview by Gary Gunderson
Neal Halfon, Director UCLA Center for Healthier Children Families and Communities at UCLA
Director, CHCFC; Professor, David Geffen School of Medicine at UCLA, Dept of Pediatrics; Professor, UCLA Fielding School of Public Health, Dept of Health Policy and Management; Professor, UCLA Luskin School of Public Affairs, Dept of Public Policy
Dr. Neal Halfon is a professor of pediatrics, health services, and public policy. Dr. Halfon’s research has spanned clinical, health services, epidemiologic, and health policy domains. For more than a decade, Dr. Halfon has worked with national, state and local initiatives aimed at improving early childhood systems. He has also played a significant role in developing new conceptual frameworks for the study of health and health care, including the Life Course Health Development (LCHD) framework.
Dr. Halfon directs the Transforming Early Childhood Community Systems (TECCS) Initiative, a collaborative venture with United Way Worldwide. He is Associate Director of the UCLA Clinical Translational Science Institute (CTSI). He also served as member of the Board on Children Youth and Families at the Institute of Medicine and National Research Council from 2001-2006. In 2006 he was awarded the annual research award from the Academic Pediatric Association for his contribution to the field of child health research.
He received his MD at the University of California, Davis, and his MPH at University of California, Berkeley. He completed his pediatric residency at UC San Diego and UC San Francisco. Dr. Halfon was a Robert Wood Johnson Clinical Scholar at both UC San Francisco and Stanford University.
Gunderson: I’m talking to Neal Halfon this morning in Chicago at Catalyst Ranch at a meeting we’re both at. Because both of us are curious about making cases for large scale, long term change. And that is an art that we constantly need help with. So both of us are in this setting. For months I’ve looked forward to talking to you, as I have watched you in Institute of Medicine webinars and in other settings. Seeing an increasingly compelling body of work that looks like a list of projects, but I’m curious, I know it’s not a list of projects in your head, it’s an integrated body of thought and practice that wants to change the world in ways that a physician would see possible. So I’m eager for the conversation. I’m just glad we’re both here as learners.
Halfon: Yeah, great, it’s great to be here with you also.
Gunderson: So I always like to begin these conversations with how did Neal become Neal?
Halfon: Good question. I got into medicine with kind of a conflict, I wanted to do something around social justice. For many years, I thought I was going to become the people’s lawyer. And then I realized that I knew a lot of people in college that were going to be the people’s lawyers and I didn’t know anybody that was going to become the people’s doctor. So I went to medical school at UC Davis and right at the beginning of medical school I had to take a psychiatry elective for six weeks. And I elected to do that at the Vacaville State Penitentiary where I could do six weeks in a group therapy with prisoners there. And I was interested in the, that time, this is going back almost 40 years, the pipeline into prison, what was actually happening. And that six-week elective turned into a full year of spending my year there.
And one of the things that I learned after I got over the shock of walking onto the main line at the prison and having all these murderers and rapists and arsonists, you know, walking all around me, sitting in the room with them for a year and hearing their stories, I realized to every single one there was a path for them to prison, and they had suffered a number of traumas along the way. So there was no accident. It wasn’t just a bad seed. These were people that had a life full of experiences that led them this direction.
Fast forward, I do my pediatric residency at UC San Diego with a marvelous inspirational doctor named Marty Stein who was all about changing the world, but was one of the best pediatricians in the country. And then I went to UC San Francisco and did the Robert Wood Johnson Clinical Scholars program. My mentor at UC San Francisco was a guy named Phil Lee. Phil Lee was President Johnson’s Assistant Secretary for Health and also President Clinton’s Assistant Secretary for Health. He was the one that rolled out Medicare and Medicaid.
When I finished my Clinical Scholars program, Phil called me in and said “I need you to go down to Palo Alto and meet with Lucile Packard. She just called me and she wants someone to do a study on kids in foster care in California.” And I said, “Okay. I said, I don’t know much about foster care.” And he said, “Well, you’ll learn.” He says, “You know about child abuse.” And I said, “Sure.” I’ve done probably two or three hundred child abuse exams in the emergency room, but I never knew where those kids went to after they were taken into care. He says, “Well this will be a good project for you.”
So I went down and met with Mrs. Packard and at that time it was just her and one program officer. And I went off to study the foster care system in California, where kids were getting health care, mental health care, and hired an anthropologist and a psychologist. And we went about sort of studying what was going on. What I found was that this was a group of children that were getting the wrong care at the wrong time in the wrong place by the wrong people, with no sense of follow up coordination of care. First thing, foster care then became my model system for understanding adversity because these kids who had all experienced extraordinary adversity. They had experienced what we now call toxic stress, but they had these in this horrible environment. And I went and set up a program at the Children’s Hospital in Oakland called the Center for the Vulnerable Child, which was basically beginning to understand, or beginning to apply what I had learned in medical school and in my residency training, that people with cancer to take care of them because they had multiple needs, both biological and psychosocial, you had social workers and psychologists and you did team care. These kids in foster care basically had social cancer and no one was taking care of them in the same kind of comprehensive integrated fashion.
So we developed a model for doing that and over the next eight years, I took care of a couple thousand children myself, that I followed in foster care and that had had all kinds of horrible things happen. And it was at that point I started to realize what I had seen in Vacaville State Penitentiary in these three-year-olds who had watched their father shoot their mother in the head or had been through something, you could see which kids were on their way to San Quentin at this point because of the kind of trauma they had gone through.
So it was out of that that I started to formulate these kind of life course theories about life course development and understanding the kinds of traumas that go on and how that sets lifelong trajectories and how there were these sensitive periods in someone’s life, in which when you were traumatized, it gets embedded in your biology. It gets embedded into how you behave and that’s hard to shake that, once those things happen. So that if we were going to change the kind of trajectories and path, need to sort of figure out how to move upstream.
And what I figured out after eight years is that we got very good, in a comprehensive way, of dealing with the toxicity in these children’s lives and smoothing things out. But we were really putting band aids on the booboos of these kids in foster care and there weren’t enough band aids and enough physicians to do it. It was all going to be kind of find and fix. And what we really needed to do is move upstream and figure out how do you actually stop these kids from being abused and neglected, but really how do you help their families be better supported so that they’re not making the kind of choices, because they had no other choices to make.
And so that led me to UCLA and probably the next 20 years of my life working on early childhood prevention and upstream brain development, upstream interventions and upstream systems. So that’s the origin story of, sort of, how I got interested in social issues, upstream issues, life course issues, prevention and, kind of, health development as a sort of leverage point for changing lifelong trajectory.
Gunderson: You’ve spent your adult life intentionally exposed to stuff that anybody normal would try to look away from. And you keep focusing and focusing and focusing and focusing. It’s really an amazing story. Do you wish you’d become a radiologist or…?
Halfon: No, no. You know…
Gunderson: I don’t mean to dis the radiologists.
Halfon: Oh, no, no. You know, it’s hard at times. And you know, there was a really profoundly influential, a couple influential articles as I was training. One was George Engle’s Biopsychosocial article that Phil Lee handed me in 1977 when it came out in Science. He said, you better read this, this is going to change the way we think about everything. And the other article is by a guy named Eric, I think it was Eric Cassell, called The Nature of Suffering and the Goals of Medicine. And it was about personhood and who we are and what suffering was about. And it raised issues from an Anglo-Western, that were very similar to, kind of, Buddhist notions of suffering. And what life and what a path to reduce suffering is about. So part of, I think, what has informed me and the way that I see the world is, sort of, on a path to reduce suffering. And we see how this suffering begins with little changes in children’s lives and then compounds. You know, as Einstein said, or it was at least attributed him, that the most powerful force in the universe is not those that attract the molecules. And then he wrote about E equals MC squared, but he said compounding. So you have little changes kids, become big changes in adults. So it’s that compounding of the effect. So how do we stop that from happening?
Gunderson: Can health compound?
Halfon: Yeah, you can use positive compounding things also. So it works both ways. And so how do you compound the assets? How do you also sort of prevent the compounding, so how do you reduce risk factors on those trajectories? How do you more protective factor? And the name of the game as those who go into high trajectories have more protective factors and more promoting factors and less risk factors. Kids living in a high income community have lots of those protective things and fewer risk and the other way around in the other community.
So the question is how do we shift that? And you do that, and that’s part of what I’ve been working on, is how do you shift the ecosystems in which children live? And right now I think that that is the challenge of our time because what we’re seeing is a very rapid change in the epidemiology of children’s health.
Part of my research career has been in monitoring changes in chronic illness, which I started in, you know, back in the 1980s. But how childhood disability has gone from 2 percent of the child population, 1960s, to now 10 percent of the population. So a steady rise in disability. But we’re also seeing, recently, increased risk in obesity, which we all are aware of. We have increasing mental health problems. And I mentioned yesterday at the meeting, that just yesterday the study came out showing that the suicide rates in girls, adolescent girls has tripled in the last 15 years.
But we’ve seen just a remarkable increase in mental health problems and neurodevelopmental disorders like autism and also in addiction disorders. So we have these four epidemics, you could throw asthma in, and these are not because of a new gene, a new germ, new chemical, they’re adaptive disorders that have to do with children living in environments that they can’t adapt to fast enough.
And you know, I grew up worrying about poverty and inequality and social isolation. I still think those are really, really, really important. Racism, structural racism, put many people at disadvantage, but we’re in a new ball game right now and the new ball game has to do with, we’re shifting from a industrial world to an information technology world and it’s a change of age. And when we go through a change of age, what is happening, as when we went from the change of age from the agricultural world to the industrial world, that change of age was associated with people getting sicker, shorter, with many more social induced kinds of problems.
And as people moved into the cities, we have juvenile delinquents and child abuse and whole child saving thing that develops during the Progressive Era, at the turn of the century. In fact, we’re only blocks away from Hull House where Jane Addams and John Dewey and others, sort of say, we have to do something very different because of this industrial age change that’s gone on.
Well, we’re going through something similar right now, in that, we’re going through a change from the industrial to an IT world, where all the rules of the game are changing and things, most importantly, are accelerating. As Tom Friedman has pointed out in The New York Times, we’re in an age of acceleration where everything’s happening much faster and we’re experiencing 10 tsunamis right now that are all happening at the same time because the world’s spinning so fast.
Gunderson: So what’s the positive? Is there anything working with us that … I mean, as you outline, there’s compounding compounders that are accelerating… a cumulative impact.
Gunderson: So what do we do?
Halfon: Well, I think one, is to start to recognize what’s actually going on. You know, we’re a little bit like drunks looking for the keys under the lamppost at this point. You know that story?
Gunderson: I’ve actually dropped my keys before, yes.
Halfon: Yeah. So, but the drunk looking for the keys under the lamppost, as you walk by and you see the guy on the floor, on the ground, crawling around looking for his keys. And after helping him for a while, you ask him, where did you lose them? And he says, 20 feet up the street. He said, why are you looking there? He says, the lights better. Well, we’ve shown a light on various things. So we’re all fiddling and moving and trying to fix that, when actually a lot of what’s going on is happening much earlier in the life course. We’ve spent a whole century sending money to the end of the life course because during the 20th century, life expectancy went from 40 years to close to 80 years. So we had to build a whole cultural scaffolding for people to live longer. So that included mortgages and insurance products and Social Security, Medicare, all these things send money to the end of the life span. And so we’re now starving the seed corn and not investing enough early in life.
Of the $4 trillion we’ll spend on healthcare in the United States, 10 percent of that will go to children. And of the 10 percent that goes to children, half of that goes to 5 percent of kids and the other 95 percent of kids basically get 5 percent of the healthcare budget. What that means is basically all children in the United States are getting budget dust. Basically the rounding error on much of what we do. And when I went to my mother, who’s 92, and talked to her about this, she said, well, that doesn’t make any sense, we should be putting in at least 25 percent into kids. And I think most people would just off the face validity, say 5 percent of $4 trillion doesn’t make sense.
So understanding the problem we’re in and understanding where the leverage points in the system are and what we should be doing differently is part of it. And my mother’s saying, and me turning to her and saying, you know what, for kids to get more of that money, you have to go to the doctor less. You’re going to the doctor four or five times a week now, Mom, could you go a few times? Oh yeah, I could go a few times less a week, that would be no problem, you know? But there’s a kind of shift that needs to happen.
Gunderson: So what do you do with the, part of what we’ve talked about at this meeting… is the “we” problem, of having that. So as a grandfather with Asa and Charlie, two extremely healthy but very privileged kids, I’d be glad to sign any advanced directive to limit my end of life care, feudal care, or even just end of life care that would prolong my life a little bit but not too much, if I knew it would go to Charlie and Asa. So if it were that way… I think every grandparent would make that choice. But what you’re describing is a much bigger, more diffuse, ‘we.’
Halfon: Yeah, and we have a very tight circle of concern right now in our country as the threats of this change that are going on and the destabilization that’s happening because of this change of age. And the 10 tsunamis, the globalization that’s changing the workforce, the increased technology change that changes everything about what we do, the digitalization that’s speeding everything up, the increased financialization that’s basically driving what’s happening in healthcare and every place else, climate change, urbanization, we have all these changes. So what’s happened after 50 or 60 or 80 years of people feeling very secure and wanting to expand and be more expressive, you know, sort of invest in human experience, everything is collapsing now. So it’s a tough time.
Gunderson: So let’s talk about this acceleration issue. Earlier this morning Tom and I interviewed Tyler Norris and I tested with him the premise that everything we hope for is already happening, but you got to look for it, and the real change strategy is to see it and nurture it. And so we’re not starting from zero.
Halfon: No, not at all.
Gunderson: But I want to test that against, frankly, your more severe logic of the compounding compounders.
Gunderson: Are there positive compounds that we could be…
Halfon: Sure and I think we understand that more than ever, that not only investing early in life, but also we know a lot more about the importance of supportive relationships and primary relationships and loving relationships early on. And we know that families need to be supported. When we look around the world at where kids are doing much better than our kids are-
Gunderson: Like, where do you look for?
Halfon: The Netherlands, where kids are the happiest, the tallest and healthiest on the planet. You know, in France and most of the Scandinavian countries, almost anywhere what you see basically, is they have a very different investment strategy. We all spend exactly, close to the same amount of money. They spend more of their money on social and educational issues early in life. And we spend it on healthcare later in life. So what they do is they’re investing in the success and health of their population, we’re paying for failure. So it’s a completely wrong headed investment strategy. So we need to change our investment strategy. And if you look at those other countries, they have three social strategies that they use for children. One social strategy is called health care. They all buy into universal health care and they pay for it, and for everybody. And they cover mental health and everything.
The second social strategy they have is early care and education. And that’s not just preschool—that’s important, we all need to have kids in preschool—but it’s all of the parent education and it’s all this stuff that happens in the first years of life. So they provide that.
The third thing they do is they provide family support. And family support is instrumental support, money when families need it, social support and psychological support.
And the reason why we’re seeing these epidemics is what’s happening with these rapid changes in our society, is ground zero is the family. And we’re not supporting families right now. And we sort of pretend as a country to be family friendly and to care about families. But in reality, we don’t put our money there. And we also sort of say, well government shouldn’t be involved with families. Well, government doesn’t have to be involved with families, but government and our resources need to support families. So families have the time to invest in their children and have the things in their community.
So part of why we’re launching this initiative across the country, called “All Children Thrive,” is to begin to sort of shift the dialogue in communities, to shift the gaze in communities towards what really matters early on in life. And the role, not just to change the service systems, health care, child welfare and mental health, those public service systems that focus on the most vulnerable, but right now we have 40 or 50 percent of children that have pretty significant problems. It’s not 14 percent anymore, which it used to be, it’s 40 to 50 percent.
So you can’t use a marginal risk strategy, where you’re just trying to bring up the tail of the curve, we have to shift the whole curve forward and that’s a systems change that’s not the service systems, it’s the ecosystem. And the place that controls the ecosystem is cities and city governments, so it’s parks and rec, it’s police, it’s education, it’s streets, it’s everything that we live, where people live. And we have to be thinking about, how do we get cities to commit to their residents, their younger, youngest residents to the future human capital and their future wealth.
Gunderson: What about the non-governmental components of the social ecology? What would, right now in North Carolina we’re transforming Medicaid and… it’s a really smart notion and lots of focus on social determinants. They reframe to talk about healthy opportunities. So lots of this is picking up some of your DNA, but there’s a question about whether there’s still room in the lives of our communities for the non-governmental part of the community?
Halfon: Oh, absolutely. But what needs to happen is government needs to sort of, either get out of the way, or start paving the roads to the future. Which they’re not. It’s like what they did is put up a barrier, said under construction and they’ve never taken the barrier down. And so we have to pave the roads to the future and make that so that all those complex community coalitions that exist, the many collective impact groups, so that they’re actually supported in the way they do it.
We have to have a whole set, we need to adapt very quickly. This change is happening fast so we need an adaptive toolkit. In an adaptive way, we need to be using foresight to sort of say, where do we need to get to in 20 years? In Charlotte, North Carolina? Or Chapel Hill? Or Greensboro, wherever. But where do we need to get to and what does it look like? What kind of design brings everybody in all the families, all the communities, all the faith groups, how do we design it for all of us? How do we learn our way forward, make the changes and make sure that we all get there?
Gunderson: I mean, this is such a compelling and obvious appealing idea. Do you sense it can happen? Do you expect it to happen? I guess I’m asking about your hope?
Halfon: Well, we got $10 million from the state legislature in California to launch All Children Thrive California. What we’re trying to do is launch a cities project in California, in which we’re building off the model of HEAL cities in California, Healthy Eating Active Living cities, where public health advocates and Kaiser went to cities and said, do you want to be part of the problem or part of the solution? Said, we want to be part of the solution. So they gave them 20 things for cities to do. They picked a couple. They’ve then got a designation as a HEAL city. They got something to put on their website and they were moving forward. We now have 200 HEAL cities in California. So we’re using that model. And so to say, how do we get an All Children Thrive cities? We’re coming up with the policies for them to do and adopt, but we’re going further than that. And where we’re going further is we’re saying, you know, you’re going to earn stars in your city if you have data on all your children so your kids aren’t invisible anymore and you can map it. You’ll get a star if you have a mayor’s Office of Child Wellbeing. You get a star if you have a children’s budget, which all the places in the Netherlands have, every city has. You’ll get a star if you have a 10 year blueprint for your city. Maybe get a star if you adopt the UN Charter on Children’s Rights.
So we start to create a set of incentives for cities to move in that direction. They’ll look at each other and say, hey, how many stars do you have? And we’re starting to talk to our legislature about should we, if city of Pasadena or city of Long Beach or the city of Watsonville, if they get six stars and their school readiness scores go up and child abuse rates go down, should there be an… so they get a pay for success, not at a clinical level, but at a city level.
Gunderson: That’s a positive compounding.
Halfon: That’s positive compounding, it’s aligning the forces, you know, to move in the right direction and to sort of see if we can do this. There are lots of cities around the country that want to do this. I’ve had conversations with people like Patrick Conway in your state, talked to people in New Orleans and Cincinnati. Cincinnati actually has an All Children Thrive Cincinnati moving already and they’re making great gains. So I think that there’s an opportunity for many, many cities to do this and move forward. There’s also great interest now across the pond. And the UK is starting to incubate All Children Thrive in the UK, turning some of the Marmot cities, that were focused on social inequality, into All Children Thrive. Because Marmot understands that if you’re going to get equity, you have to get equity from the start. And this is a way of jump starting that. We’re also working with the Netherlands now, where all the, it’s like Lake Wobegon, right? Where all the kids are tall, healthy and happy in the Netherlands because they’re seeing the same epidemics of obesity, mental health, neurodevelopmental problems, addiction disorders there.
Gunderson: So we need to slip back into our meeting before they notice we’re gone. But, sort of, asking a question. You and I are not kids anymore. And I’m curious about whether you’re seeing the next Gen of researchers and gifted doctors that are moving into this space you’ve, sort of, broken open?
Halfon: It’s hard for them, the next generation. Because the rules of the game in the academic medical centers, is that you have to do incremental research and build your portfolio. I did that. I had to publish, you know, before I said, screw it, I have to actually deal with stuff that’s important. I had to publish 150 papers, you know, before that. So then I became, kind of, untouchable or no one’s going to give me a problem. I mean, I still publish and I still support people, but I’m pretty much dedicated to this, sort of, innovation and change agenda.
It’s very hard to sort of support that for junior people. I think where there’s real … And we need to do that and we need, in a sense, places like the Robert Wood Johnson Foundation that trained me in becoming a change agent to actually start training change agents in a really different way than I think we’re doing presently. Not just RWJ, but all the rest of them. And I think that that’s necessary. But we need much more diverse leadership and not just diverse in terms of color, but we need diverse in terms of skills and really thinking about what a new skill set is, you know, so if you’re going make these kinds of changes. And also starting younger, you know, with kids in high school and in college and making them part, because they care deeply about their future.
Gunderson: This could very well be where health systems could be a critical part of the on ramp into the creation of an ecology of thought leaders that we need now, but we’re going to need them even more in 10 years. Well, you know, this has been great. I know we need to slip back in, but I couldn’t be more grateful for what you’ve done with your life and what you’re leading. And yeah, we want to be one of your Thrive cities.
Halfon: Well, I hope that that’s the case. I, you know, I was just in North Carolina a couple of weeks ago, so, talking it up a bit, so I hope we can make that happen. So thanks. And thanks for giving me the opportunity to spout off here a little bit.
Gunderson: Oh, it is very smart. Thanks.