by Paul Tough
When Dozier first arrived at Fenger, an ambitious and determined thirty-one-year-old, she believed that the basic tool kit of the modern education reformer contained everything she needed to turn things around for the school’s students. She had spent a year in a highly competitive principal-training program called New Leaders for New Schools, which emphasized to trainees that a dynamic leader could raise students’ achievement to high levels, no matter what their socioeconomic circumstances, as long as she had a committed staff. Dozier cleaned house at Fenger, replacing several administrators and most of the teachers; when I first sat down with her in her office at Fenger, a little more than a year after she took the job, her seventy-member staff included only three teachers from the school’s pre-Turnaround days. Most of the new teachers were young, ambitious, and non-tenured, which meant they would be relatively easy for Dozier to replace if they didn’t measure up to her standards.
When we spoke, though, Dozier said that her thinking about schools had been changed by her time at Fenger. “I used to always think that if a school wasn’t performing, that it was strictly because there was a bad principal, or there were bad teachers,” she explained. “But the reality is that at Fenger, we’re a neighborhood school, so we’re just a reflection of the community. And you can’t expect to solve the problems of a school without taking into account what’s happening in the community.”
As Dozier got to know the students at Fenger, she found herself repeatedly taken aback by the severity of the problems they faced at home. “The majority of our students are living in poverty, from check to check,” she told me. “A lot of them live in neighborhoods with gang problems. I can’t think of a single kid at the school who doesn’t face some kind of serious adversity.” A quarter of the female students were either pregnant or already teenage mothers, she said. And when I asked her to estimate how many of her students lived with both biological parents, a quizzical look came over her face. “I can’t think of one,” she replied. “But I know we have them.”
The threat of violence seemed always to be looming over Fenger’s students as well. Chicago’s murder rate is twice as high as the rate in Los Angeles and more than double the rate in New York City. Gangs have a bigger and more lethal presence in Chicago than in any other major American city, and when Dozier came to Fenger, there had been a recent spike in gun violence among young people: in 2008, eighty-three school-age teenagers were murdered in the city, and more than six hundred were shot but survived.
Though Dozier had been expecting the turnaround of Fenger to be a challenge, nothing prepared her for what happened on her sixteenth day on the job. A major fight broke out a few blocks from the school, involving maybe fifty teenagers, mostly Fenger students. There were no guns or knives, but some kids picked up railroad ties and started using them as clubs. A sixteen-year-old Fenger student named Derrion Albert who had waded into the fight was hit on the head with a railroad tie and then punched in the face and knocked unconscious. While he was on the ground, a few other young men kicked him in the head, and the combined blunt-force trauma killed him.
In its most basic elements, Derrion Albert’s death in September of 2009 was not all that different from any of the dozens of other violent deaths of Chicago high-school students that year. But the fight and Albert’s killing were captured on video by a bystander, and that fall the video became first a YouTube sensation and then a cable-news fixture. Local and national media descended on Fenger. For weeks, the streets around the school were lined with TV satellite trucks, and prayer vigils and protests were held in front of the school. The U.S. attorney general, Eric Holder, came to meet with students. Then in October, Fenger made news again when three vicious gang fights broke out simultaneously on three separate floors of the school. Dozens of police cars arrived, five students were arrested, and the whole building was put on lockdown for three hours.
After the schoolwide brawl, Dozier instituted what she called a zero-tolerance policy for violent behavior and behavior that might lead to violence: If students threw up gang signs or exchanged gang handshakes in the hallway, Dozier gave them automatic ten-day suspensions. If they fought, she called the police and had them arrested, and then she did her best to expel them from Fenger permanently. When I started spending time at Fenger, more than a year after Albert’s death, the halls were generally quite orderly, though they certainly didn’t seem normal. There were always thick-armed security guards patrolling the hall; students couldn’t go anywhere without their IDs on Fenger lanyards around their necks, and when a student needed to go to the bathroom in the middle of class, she had to carry a giant hall pass, two feet long and bright yellow. Between classes, the synthesizer-laden theme from Beverly Hills Cop played on speakers in the hallways; students knew they had to make it to the next class before the last note sounded. Despite the firm rules, there were still disruptions; the first time I came to Fenger to interview Dozier, we were interrupted twice by shouts in the hallway, arguments that she had to rush off to help adjudicate.
Midway through her second year as principal, Dozier told me that she was beginning to feel that the most important tools at her disposal were ones that didn’t have much to do with classroom instruction. In the wake of Derrion Albert’s murder, Holder and Arne Duncan pledged $500,000 in federal money to set up afterschool programs in anger management and trauma counseling at Fenger, and the school began to refer to counseling not just students but their families as well. Dozier enrolled twenty-five of her most troubled students in an intensive mentoring program. She was looking for any kind of intervention that might address what now seemed to her to be the most pressing crisis at Fenger—not her students’ academic deficits, though those remained acute and distressing, but a deeper set of problems, born out of her students’ troubled and often traumatic home lives, that made it difficult for them to get through each day. “When I came into this job, I discounted questions like ‘What families do kids come from?’ and ‘What effect does poverty have on children?’” Dozier said to me one morning. “But since I started working at Fenger, my thinking has evolved.”
2. Nadine Burke Harris
What effect does poverty have on children? Halfway across the country, this was the question Nadine Burke Harris was asking as well. But she was a doctor, not an educator, and so she approached the question from the perspective of her patients’ physical health. Since 2007, Burke Harris had been the lead pediatrician of the Bayview Child Health Center in the Bayview–Hunters Point neighborhood of San Francisco, a bleak industrial area tucked away in the city’s southeast corner that is home to some of the city’s biggest and most violent housing projects. When Burke Harris founded the clinic, she was a recent graduate of the Harvard School of Public Health, a fresh young idealist hired by the California Pacific Medical Center, a well-funded private hospital chain, to take on a vaguely defined but noble-sounding mission: to identify and address health disparities in the city of San Francisco. Those disparities were not hard to find, especially in Bayview–Hunters Point: the rate of hospitalization for congestive heart failure there was five times as high as it was in the Marina District, a few miles away. And before Burke Harris’s clinic opened, there was only one pediatrician in private practice in a community with more than ten thousand children.
Burke Harris had studied health disparities at Harvard, and she knew what the public-health playbook said you should do to remediate them: improve access to health care, especially primary care, for low-income families. When the clinic opened its doors, Burke Harris targeted the low-hanging fruit of pediatrics, the health issues where the disparities between rich and poor children were most obvious and best understood: asthma management, nutrition, vaccinations for diphtheria and whooping cough and tetanus. And in just a few months, she made significant headway. “It turned out to be surprisingly easy to get our immunization rates way up and to get our asthma hospitalization rates way down,” she told me when I first visited her clinic. And yet, she explained, “I felt lik
e we weren’t actually addressing the roots of the disparity here. I mean, as far as I know, no child in this community has died of tetanus in a very, very long time.”
Burke Harris found herself in a situation much like Dozier’s. Here she was, in her dream job. She had ample resources, she was well trained, she was working hard—and yet she didn’t seem to be making much of a difference in the lives of the young people she was trying to help. They were still surrounded by violence and chaos, at home and in the streets, that was clearly taking a grave toll on them, both physically and emotionally. Many of the children she saw in the clinic seemed depressed or anxious, and some of them were downright traumatized, and the stress of their daily lives expressed itself in a variety of symptoms, from panic attacks to eating disorders to suicidal behavior. She sometimes felt less like a primary-care pediatrician and more like a battlefield surgeon, patching up her patients and sending them back to war.
Burke Harris went looking for answers, and her quest took her into a new and unfamiliar conversation about poverty and adversity, one that was taking place not in public-policy magazines and at political science symposiums but in medical journals and at neuroscience conferences. Gradually, Burke Harris became convinced of what had at first seemed a radical idea: that in neighborhoods like Bayview–Hunters Point and Roseland, many of the problems we generally think of as social issues—the province of economists and sociologists—are actually best analyzed and addressed on the molecular level, down deep in the realm of human biology.
3. The ACE Study
Burke Harris’s journey began with a medical-journal article that Whitney Clarke, a psychologist on the clinic’s staff, dropped on her desk one day in 2008: “The Relationship of Adverse Childhood Experiences to Adult Health: Turning Gold into Lead.” The author was Vincent Felitti, the head of the department of preventive medicine at Kaiser Permanente, the giant health maintenance organization based in California, and the article described the Adverse Childhood Experiences study, commonly called the ACE study, that Felitti had conducted in the 1990s with Robert Anda, an epidemiologist at the Centers for Disease Control in Atlanta. When Burke Harris read the paper, she told me, something clicked: “The clouds parted,” she said with a smile. “Angels sang. It was like that scene at the end of The Matrix where Neo can see the whole universe bending and changing.”
Beginning in 1995, patients enrolled in the Kaiser HMO who came in for comprehensive medical exams were mailed questionnaires asking them to relate their personal histories in ten different categories of adverse childhood experiences, including physical and sexual abuse, physical and emotional neglect, and various measures of household dysfunction, such as having divorced or separated parents or family members who were incarcerated or mentally ill or addicted. Over the course of a few years , more than seventeen thousand patients completed and returned the questionnaires—a response rate of almost 70 percent. As a group, the respondents represented a very mainstream, middle- to upper-middle-class demographic: 75 percent were white; 75 percent had attended college; the average age was fifty-seven.
When Anda and Felitti tabulated the responses, they were surprised, first, by the sheer prevalence of childhood trauma among this generally well-off population. More than a quarter of the patients said they had grown up in a household with an alcoholic or a drug user; about the same fraction had been beaten as children. When the doctors used the data to assign each patient an ACE score, giving them one point for each category of trauma they had experienced, they found that two-thirds of the patients had experienced at least one ACE, and one in eight had an ACE score of 4 or more.
The second and more significant surprise came when Anda and Felitti compared the ACE scores with the voluminous medical histories that Kaiser had collected on all the patients. The correlations between adverse childhood experiences and negative adult outcomes were so powerful that they “stunned us,” Anda later wrote. What’s more, those correlations seemed to follow a surprisingly linear dose-response model: the higher the ACE score, the worse the outcome on almost every measure from addictive behavior to chronic disease. Anda and Felitti produced one bar chart after another from the data, and each one traced more or less the same shape. Along the bottom of each chart, the x-axis, the doctors plotted the number of ACEs that patients had experienced. Along the y-axis, they indicated the prevalence of a specific undesirable outcome: obesity, depression, early sexual activity, history of smoking, and so on. On each chart, the bars rose steadily and consistently from left (0 ACEs) to right (more than 7 ACEs). Compared to people with no history of ACEs, people with ACE scores of 4 or higher were twice as likely to smoke, seven times more likely to be alcoholics, and seven times more likely to have had sex before age fifteen. They were twice as likely to have been diagnosed with cancer, twice as likely to have heart disease, twice as likely to have liver disease, four times as likely to suffer from emphysema or chronic bronchitis. On some charts, the slopes were especially steep: adults with an ACE score above 6 were thirty times more likely to have attempted suicide than those with an ACE score of 0. And men with an ACE score above 5 were forty-six times more likely to have injected drugs than men with no history of ACEs.
The behavior outcomes, though surprising in their intensity, at least made some intuitive sense. Psychologists had long believed that traumatic events in childhood could produce feelings of low self-esteem or worthlessness, and it was reasonable to assume that those feelings could lead to addiction, depression, and even suicide. And some of the health effects that turned up in the ACE study, like liver disease and diabetes and lung cancer, were most likely the result, at least in part, of self-destructive behaviors like heavy drinking, overeating, and smoking. But Felitti and Anda found that ACEs had a profound negative effect on adult health even when those behaviors weren’t present. When they looked at patients with high ACE scores (7 or more) who didn’t smoke, didn’t drink to excess, and weren’t overweight, they found that their risk of ischemic heart disease (the single most common cause of death in the United States) was still 360 percent higher than those with an ACE score of 0. The adversity these patients had experienced in childhood was making them sick through a pathway that had nothing to do with behavior.
4. The Firehouse Effect
That initial ACE study led Burke Harris to other research papers, and before long she was immersed, staying up late every night reading articles from medical journals and tracking down footnotes and references on PubMed, the online medical database. The research she compiled during those furious months of study now sits in four fat binders on the shelf of her office at the clinic. The papers within span many scientific disciplines, but most of them are rooted in two fairly obscure medical fields: neuroendocrinology (the study of how hormones interact with the brain) and stress physiology (the study of how stress affects the body). Although Anda and Felitti initially didn’t understand the biological mechanisms at work in their ACE data, scientists have reached a consensus in the past decade that the key channel through which early adversity causes damage to developing bodies and brains is stress.
Our bodies regulate stress using a system called the HPA axis. HPA stands for “hypothalamic-pituitary-adrenal,” and that tongue-twisting phrase describes the way that chemical signals cascade through the brain and the body in reaction to intense situations. When a potential danger appears, the first line of defense is the hypothalamus, the region of the brain that controls unconscious biological processes like body temperature, hunger, and thirst. The hypothalamus emits a chemical that triggers receptors in the pituitary gland; the pituitary releases signaling hormones that stimulate the adrenal glands; and the adrenal glands then send out stress hormones called glucocorticoids that switch on a host of specific defensive responses. Some of these responses we can recognize in ourselves as they happen: emotions like fear and anxiety, and physical reactions like increased heart rate, clammy skin, and a dry mouth. But many effects of the HPA axis are less immediately apparent to us, even
when we’re the ones experiencing them: neurotransmitters activate, glucose levels rise, the cardiovascular system sends blood to the muscles, and inflammatory proteins surge through the bloodstream.
In his insightful and entertaining book Why Zebras Don’t Get Ulcers, the neuroscientist Robert Sapolsky explains that our stress-response system, like that of all mammals, evolved to react to brief and acute stresses. That worked well when humans were out on the savanna running from predators. But modern humans rarely have to contend with lion attacks. Instead, most of our stress today comes from mental processes: from worrying about things. And the HPA axis isn’t designed to handle that kind of stress. We “activate a physiological system that has evolved for responding to acute physical emergencies,” Sapolsky writes, “but we turn it on for months on end, worrying about mortgages, relationships, and promotions.” And over the past fifty years, scientists have discovered that this phenomenon is not merely inefficient but also highly destructive. Overloading the HPA axis, especially in infancy and childhood, produces all kinds of serious and long-lasting negative effects—physical, psychological, and neurological.
The tricky thing about this process, though, is that it’s not actually the stress itself that messes us up. It is the body’s reaction to the stress. In the early 1990s, Bruce McEwen, a neuroendocrinologist at Rockefeller University, proposed a theory of how this works, one that is now broadly accepted in the field. According to McEwen, the process of managing stress, which he labeled allostasis, is what creates wear and tear on the body. If the body’s stress-management systems are overworked, they eventually break down under the strain. McEwen called this gradual process allostatic load, and he says that you can observe its destructive effects throughout the body. For example, acute stress raises blood pressure to provide adequate blood flow to the muscles and organs that need to respond to a dangerous situation. That’s good. But repeatedly elevated blood pressure leads to atherosclerotic plaque, which causes heart attacks. That’s not so good.