A rocket explodes.
The
force of the explosion causes air molecules to vibrate against each other. These vibrations spread in a wave, each air
molecule rubbing up against the next, communicating the atmospheric inheritance
of the bomb. The vibrating wave eventually
arrive at a young boys ear, where it bounced around the ear canal, finally
striking the tympanic membrane at its end.
Shortly after the membrane begins to vibrate, bones behind it follow
suit, sending the event deeper into the young boy’s body. Eventually the vibrations make it to a fluid
filled canal in the inner ear. As it
spreads down this narrow corridor it comes into contact with microscopic hair
follicles which beat back and forth, struggling against the explosive
legacy. In response to the struggle, ion
channels in the base of the follicles open, turning the sound vibrations into electrical impulses. These signals shoot down an attached nerve, aimed directly at the
brain.
If you’ve followed the news
recently, you know that Israel and Hamas are engaged in a vicious conflict over
control of Gaza. Hamas, citing grievances over a stern Israeli blockade of the
region, has fired nearly
3500 rockets at Israeli cities since the conflict
began in mid-July.
Israel has
responded by conducting thousands of airstrikes on targets in Gaza and sending
in ground troops to destroy Hamas’ network of underground tunnels.
This is not a new story line as similar fighting has occurred between the two groups time and again ad
nauseam. This conflict has been going on in its modern form for more than 7
decades.
With such a long history of incredible violence, how do we begin to measure the impact of this conflict?
The traditional way is to tell the
story in numbers.
In the press, this is
primarily described by numbers of people killed and displaced. The best
estimates (and good, truthful estimates are really
hard to come by) I
have read say around 2000 Palestinians have been killed and 425,000 displaced
by the fighting.
More than 12,000 Gazan
homes have been destroyed and economic costs have been devastating.
Israel has suffered 3 civilian and 64 military
deaths (to be fair, while the numbers are smaller, they also suffer the daily
consequences of living under fire from rockets for the last several
years).
Of particular note is the number
of kids affected by the campaign.
UNICEF
estimates 400 Palestinian kids have been killed (20% of total Palestinian
casualties) and 375,00 have been displaced (79% of refugees) (Source
here and
here). Commentators,
peace activists, and war hawks alike throw these numbers around as ways to
assess the conflict’s impact on the people, community, nation, local economy,
or what have you.
My contention is that, while
describing a horrible situation, these numbers tell a limited story.
Death and displacement describe what is
happening now, but do little to communicate the human experience of the war or
the future consequences of these events.
We could further discuss economic cost, poll numbers, conflict length,
and even DALYs (
an awesome, but limited measure of disease burden used by
public health officials),
but we would still miss a certain human experience element that such analyses
inevitably leave out.
I would like to
propose a novel mechanism for measuring conflict impact that both communicates
the deleterious
experience as well as
predicts the negative
consequences of
such conflicts. And of course with me, the answer is a pediatric answer.
There is an emerging concept in the
world of Pediatrics about the role that stress plays in childhood
development.
A landmark study from 1998
looked at more than 17,000 kids and how they responded to adverse childhood
experiences (ACE).
ACEs are defined as
experiences such as abuse, neglect, and household dysfunction.
Researches classified the number of ACEs a
kid had and looked at associations with health behaviors and disease
outcomes.
The results were
stunning.
The number of ACEs a kid experienced
correlated with adverse health outcomes in a
dose-dependent manner.
In
other words, the more ACEs, the unhealthier the individual was as an
adult.
This association was true for
health behaviors such as increased drug abuse, alcohol abuse, smoking, risky
sex, teen pregnancy, and partner violence.
Moreover the association held true for health outcomes of some of the
most common causes of morbidity and mortality such as heart disease, liver
disease, lung disease, depression, STDs, fetal death, and suicide (
Source).
This study provided clear insight about the
effects our experiences have on our health.
From this study, a science of
pediatric stress has blossomed.
The
foundation of this science is the fact that the body has robust mechanisms to
respond to and cope with stress. The stress caused by ACEs overwhelms the
body’s ability to cope and so has been termed “toxic stress” (TS). Research has
demonstrated numerous biological changes associated with TS.
Cortisol is a hormone released from your
adrenal glands to help your body cope with stress by raising blood pressure and
blood glucose levels and mediating activation of the “fight-or-flight”
response. Studies have shown that kids who experience TS have prolonged
elevation of cortisol levels.
Long-term
exposure can cause many adverse consequences such as immune system dysfunction,
muscle tissue breakdown, electrolyte imbalances, and neurological damage.
Concerning this last effect, fancy brain
imaging studies have shown that prolonged cortisol exposure causes actual
changes in the architecture of the brain areas associated with fear and emotion
regulation (amygdala), memory and emotion integration (hippocampus), and
decision-making and action control (prefrontal cortex).
While this is an overview of stress from
10,000 feet, doctors generally cite these mechanisms as the biological
mediators of the adverse health outcomes associated with ACEs and TS
(If you have extra nerd time,
here's an awesome PDF overview, here's a
more technical paper from the AAP).
In split seconds the
explosive message reaches the young boy's brainstem. From its protected vantage point at
the base of the skull it disperses the message up and throughout the cerebrum,
the command center. The
auditory cortex hears the message and sends it to the hippocampus to try to
remember where such reverberations had been heard before. The hippocampus
remembers the destructive effects of such a sound and passes it along to the
amygdala to decide how it should feel.
The amygdala instantly knows the only feeling to be felt is fear. As it passes the message down the line the amygdala sounds the alarm, letting the reserves know it was time to act. From a distance, sitting on the kidneys, the
adrenal gland hears the alarm. Cortisol
and adrenaline come pouring out of the gland into the bloodstream, preparing
the body to act. At the same time, the
prefrontal cortex activates, sending sparks of cognition to the muscles,
preparing them to go. The boy’s eyes dilate, sweat glistens his brow, his
heart starts pounding, his muscles tense.
Meanwhile the message reaches the black box of his consciousness. As his attention shifts to the explosive
sound, he can only think one thing: danger.
The fascinating thing to me is how
this should expand our narration of health and disease. Normally, when there is something wrong with
our bodies we (both as lay people and as doctors) explain it as a present tense
state of being – “I have a cold”,
“You are a smoker”. This, of course, is the most natural way to
talk about the state of our bodies, but it has the effect of anchoring our
focus to the present without giving much thought to the proximate causes of
such states. When we do explain causes,
we tend not to go back too many degrees from the present: “why do I have a
cold?”, “Because you took care of the snotty kid down the street
yesterday.” It is not within our mental
purview to explain how the kid got the cold from sticking a toy in his mouth at
the mall, which became infected when a janitor touched it after blowing his
nose in the same snot rag all day, who in turn had been infected by…. and so
forth. The beauty of TS theory is that
we now have a strong anchor point in the past and a plausible biological
mechanism over time to expand the depth of our disease narration in the
present.
Now let’s finally return to our
discussion about measuring conflict. I
said above that I want a measurement that communicates the experience and the consequence
of conflict. Stress is the perfect way
to communicate both of these. A body’s
response to subjective experience over time has measurable consequences, both
in terms of biological changes and life outcomes. Such a discussion would have a more emotional
impact than statistics. We can all
relate to the experience of stress and thus understand to some degree what it
is like that these other humans are undergoing this experience. It would also be more longitudinal than just
quoting death totals and economic costs, as we could extrapolate from the
present time not only those effects, but also the myriad health, emotional, and
psychological consequences as well. With
time and further research, perhaps we could even delineate how such acute
stressors cause changes in culture, sociology, government, religion, etc. Humans are the basic functional unit of all
of these structures, so a dynamic view of how humans change over time in
response to stress would do much to inform initiatives that prevent, mitigate,
and repair the damage of such horrible situations.
What would such a measurement look
like? I propose the base value would be “Toxic Stress Units” (TSUs). We could take random samples from the
population of pre- and post-conflict cortisol levels, fight-or-flight response
reactivity, and neuronal metabolism of the specific brain areas mentioned
above. We could index these values into
a basic unit and then measure the increase of TSUs caused by the conflict. Longitudinal studies could look at how
adverse health (or economic, political, etc) outcomes correlate with TSU levels
over time. Once we develop a good
understanding of TSUs, public health experts could use them to craft policies
on how to approach post-conflict development, peace activists could use them to
decry the evil-yet-specific, horrendous-yet-measurable effects of war on
children, and policy developers could use them to account for the comprehensive
burden that conflicts will have on the major political and economic structures
of a nation.
And how
long would all this take? Probably decades to forever. I literally started thinking about this last
week and as far as I know, there are no such discussions in the
literature. So it has not progressed
beyond the stage of a fanciful thought in my mind (well I guess now it’s a
speculative blog post). But I do think
it is interesting and worth chewing on.
There is a
last, larger point I will make from all this.
While toxic stress units are not yet a real thing, the horrible pain we
inflict on each other certainly is.
In
the Jewish Old Testament there is a word for peace that is transliterated as
“shalom” (and, though I’m less familiar,
Muslim texts have a similar word, “Salam”).
This word means something beyond a mere absence of hostility.
Shalom has been defined as “a
comprehensive well being” or “universal flourishing, wholeness, and delight—a
rich state of affairs in which natural needs are satisfied and natural gifts
fruitfully employed, a state of affairs that inspires joyful wonder as its
Creator and Savior opens doors and welcomes the creatures in whom He
delights.
Shalom,
in other words, is the way things ought
to be.”
I believe through this
discussion about adverse childhood experiences, stress, and health outcomes,
we’ve skimmed the surface of this idea.
There is a
way things out to be,
there is a right relationship between ourselves, our world, our Creator, and
our fellow man.
Disruption of these
relationships feed back on each other to cause disease, and wars, and death,
and destruction, and elevated TSUs.
The
Israeli-Palestinian conflict has been ongoing for more than
7 decades.
There is no stopping it if we cannot change
how this conflict is seen and what this conflict is about.
By talking in terms of TSUs, we might shift
the focus from winning a battle to promoting shalom.
By focusing on shalom, then the answer is not
a geo-political reconfiguration, but rather a human and relational
restoration.
Over the years, his
body becomes veteran to the sound of explosions. His ears are attuned to its nuances, his hippocampus remembers well
what it foretells, his prefrontal cortex is practiced in its response. Cortisol is his constant companion and
epinephrine an old friend. And then
there’s the amygdala. Long ago it
replaced fear as part of its response with something much stronger. The amygdala learned to numb the pain, to
blunt its response, by washing him in that most potent of anesthetics:
hate. It is hate that now bends the
young man’s knee. Hate that feels the
weight of the weapon on his shoulder. Hate
that lowers his head to take aim. Hate
that flexes his finger and hate that pulls the trigger.
And the rocket explodes.
