It’s a strange fact that the human body contains more bacterial cells than human ones.
It’s an even stranger fact, then, that if just a few bacteria find their way into the wrong parts of the body, it can be devastating. The young woman cocooned in her hospital bed in front of me had not one but two strains of bacteria coursing through her veins, multiplying on her heart valves, lodging in her lungs.
“Good morning!” I said in my most cheerful predawn, precaffeinated voice.
“Go away,” she muttered, somewhere under the covers. After several days of similarly warm greetings, I knew what to expect.
“It’s important that I listen to your heart,” I stood firm.
“It’s important that you go away.”
Maybe it’s better if I come back later, I thought.
She was a frustrating patient. She had a long history of injection drug use and was recently admitted to a nearby hospital with a high-grade fever and drenching night sweats. She was found to have endocarditis—a dangerous condition in which bacteria attach to and damage heart valves and can spurt off to seed and destroy other organs. She was promptly started on powerful antibiotics but soon left because she felt her heroin withdrawal wasn’t being treated sufficiently. When she came to our hospital a few days later, having injected with unsterile needles in the interim, she now had a second type of bacteria in her blood and felt worse than before.
When she threatened to leave, I again emphasized how dangerous her condition was, that it required a long course of antibiotics, that stopping and starting treatment might breed bacterial resistance and make it even harder to treat. I could tell she wasn’t listening, so I asked about the colorful blanket she was clutching to her chest. Through sobs, she told me it was her daughter’s blanket. Her daughter had just turned 4 and was staying with a family friend while she herself had been struggling with drug use, rehab stints, and hospitalizations.
She decided to stay in the hospital—for now, for her daughter. She didn’t want to die and leave her daughter alone, the way her mother had left her when she committed suicide. Her father had gone to prison the following year. She then went to live with a distant aunt, whom she despised, and started using drugs shortly after.
When I thought of her daughter—just 4 years old—who would almost certainly have a similarly chaotic childhood, I couldn’t help but wonder if in 20 years I would be having an equally disheartening conversation with her, alone in a cold hospital room somewhere, while she clutched her own child’s blanket for comfort and a reason to live.
We as a country have recently begun the difficult and important conversation about social mobility and intergenerational wealth. A related—though less discussed—problem is that of intergenerational health. It is increasingly clear that our health is powerfully shaped by our own early childhood experiences, as well as by the struggles and triumphs of our parents and grandparents.
This process begins in the womb—and oftentimes before. A wealth of research now supports the notion that maternal well-being before, during, and after pregnancy has substantial long-term health effects for children. Children born to mothers with high levels of stress hormones during pregnancy are more likely to become addicted to nicotine as adults. Offspring of mothers who smoke have higher rates of obesity and poorer cardiovascular health decades later. Women who struggle with mental illness before pregnancy have more childbirth complications including low–birth weight babies and stillbirths.
Early childhood experiences seem to have an equally profound impact on long-term health. For example, infants who sleep less than 12 hours per day are twice as likely to be overweight as preschoolers—and those who grow up in single-parent households with less education and lower incomes are at highest risk. Boys whose fathers are more involved in parenting have fewer behavior problems as adolescents and are themselves more positive fathers to their children. Witnessing intimate partner violence as a child can increase one’s likelihood of experiencing and perpetrating it as an adult.
Unsurprisingly, children of parents with substance use disorders are less likely to have stable home environments and more likely to experience depression and anxiety. They are also more likely to struggle with substance abuse themselves. Even as children, they have higher hospital admission rates, longer lengths of stay, and larger hospital bills. One study found that parental substance abuse accounts for more than 70 percent of all child welfare spending in the United States.
We routinely check blood pressure and cholesterol to identify and manage patients at high risk for cardiovascular disease. We should apply the same principles to screen children and young adults whose backgrounds place them at highest risk for substance abuse and mental illness.
Many of the most intractable, damaging, and expensive health problems have their roots in mental illness and substance abuse. But even in the most resource-rich health systems, access to psychiatric care is limited at best. The United States spends less than 6 percent of its health care budget on mental health, and access to mental health services is worse than for other health services. A shortage of mental health professionals is exacerbated by the fact that psychiatrists are less likely than other specialists to accept insurance. Not surprisingly, then, the majority of adolescents with mental health disorders do not receive treatment, and this problem is particularly acute for minorities with alcohol and drug abuse issues.
A greater emphasis on mental health must be coupled with a greater emphasis on social support. The United States spends far more on medical care than other developed countries do. But if one broadens the scope of health care to include undeniably health-promoting social services like rent subsidies, employment programs, and family support services, it spends less—far less. What’s now clear is that we disproportionately allocate resources to health care over social support and, as compared to countries with more balanced spending, continue to lag behind on a variety of health metrics from infant mortality to life expectancy.
Like most problems in health care, this one has no easy answers. An important first step is appreciating how profoundly our past affects our future. We must recognize that the scars left by societal insults and destructive personal decisions last not years but sometimes generations. Breaking this cycle will require a significant reallocation of resources both within and around our health care system.