Nadine Burke Harris’s The Deepest Well: Healing the Long-Term Effects of Childhood Adversity is a 2018 nonfiction book that explores the evolving science on the relationship between adverse childhood experiences (ACEs) and health disparities. Burke Harris is a pediatrician, a founder of San Francisco’s Center for Youth Wellness, and the first surgeon general of California. In her book, she recounts how her pediatric practice in San Francisco’s Bayview community helped her link childhood trauma to long-term health problems. Using powerful anecdotes, episodes from medical history, summaries of major research, and expositions on the biology of stress, Burke Harris makes the case for developing protocols to identify and treat toxic stress responses early in life to improve health and educational outcomes for children.

This guide is based on the 2018 Mariner/Houghton Mifflin print edition. Note that the book includes descriptions of gun violence, child sexual abuse, physical abuse, and domestic abuse.

Plot Summary

The Deepest Well describes how Burke Harris’s thinking on the effect of adverse childhood experiences (ACEs) on health outcomes evolved from 2007 to 2017. She presents this evolution in four sections.

In Part 1, “Discovery,” Burke Harris recounts opening a pediatric clinic in Bayview-Hunter’s Point, an under-resourced community in San Francisco, because she believed the community needed better access to healthcare, a necessary step in addressing health disparities between its residence and more affluent communities nearby. Despite having greater access to healthcare, however, children in Bayview continued to have chronic health problems. In 2007, Burke treated Diego, a seven-year-old whose rate of growth had slowed substantially when he was four, the year when he was sexually abused.

Diego’s case led Burke Harris to suspect that childhood trauma was a catalyst for poor health outcomes later. Like John Snow, the English physician who rejected the prevailing theory of the causes of disease and figured out that a well in an English neighborhood in the 1850s was the source of a cholera outbreak, Burke Harris began to suspect that modern medical diagnosis was missing the true cause (the equivalent of the well) in determining health disparities. Burke began a decade-long hunt to find the underlying biology that connected trauma to poor health later. Vincent Felitti’s (and others’) 1998 study on the effect of ACEs on mortality in adults supported her theory that childhood pasts shaped adult health, and Burke Harris was surprised that her medical education didn’t include that information.

In Part 2, “Diagnosis,” Burke Harris details the biological systems that control the stress response, the body’s way of reacting to environmental stimuli it perceives as a threat. Persistent stressors (the equivalent of living with a bear, according to Burke Harris) damage the body’s intricate system for turning the stress response on and off. Genes and the epigenome (the system for turning gene expression on or off) also contribute to long-term and generational toxic stress responses. Felitti’s research revealed that having a buffering caretaker blunts some of the effects of ACEs, as do mindfulness, exercise, sleep, and good nutrition. Burke Harris hoped that these insights would help her more effectively care for her patients, but she lacked the resources to do rigorous research to prove that such intervention measures were effective.

In Part 3, “Prescription,” Burke Harris describes turning her focus to changing medical practice in the Bayview clinic to address her patients’ immediate needs. Using multidisciplinary treatment teams and a screening tool to quantify the number of ACEs, the clinic had some successes. Lack of resources still prevented Burke Harris from sharing her insights in a form that could shift the practice of preventive health, so with encouragement and fundraising support from other doctors, politicians, and leaders of nonprofits, Burke Harris opened the Center for Youth Wellness (CYW) in 2012 to do that work (despite some pushback from community activists). The CYW’s work yielded a refined ACEs screening tool that was easier for other sites to use and greater opportunities for Burke Harris to engage with collaborators far beyond San Francisco. Her personal relationships with high-achieving women from many industries taught her that ACEs had an effect on everyone regardless of class and race.

In Part 4, “Revolution,” Burke Harris describes how her participation in national conferences, a TED talk, and growing collaborations with people working in education and other fields helped her see how knowing about the effect of ACEs could transform the lives of children—and the adults they’d become. Fully benefiting from this awareness, however, required people to realize that the toxic stress response is universal instead of particular to poor people or people of color. In her own life, Burke Harris used her awareness of toxic stress to navigate a pregnancy loss and to understand how having a mother with an untreated psychological illness was an ACE that had an effect on her and a brother who had a stroke.

Burke Harris returns to the story of Diego (when he’s 17, just before the book’s publication) to show that ACEs will always make Diego sensitive to stressors but that intervention measures like therapy, mindfulness training, and advice on nutrition and sleep can help him navigate both positive and negative changes in his life. Burke Harris closes with a vision of a world in which screening for ACES and intervention for children is early, universal, and successful enough to at last treat the underlying causes of health disparities. Through her use of storytelling, personal anecdotes, and easily understandable explanations of the science of toxic stress, Burke Harris makes it more likely that this vision will become a reality.