Toxic Stress, Behavioral Health and the Next Major Era in Public Health

Prior to the elaboration of the germ theory in the 19^th century, infectious diseases and epidemics presented great threats to the public's health.  The preventive and treatment technologies that resulted from an understanding of the germ theory arguably caused the greatest improvement in public health ever achieved – at least among developed nations.  In this paper we argue that our greatest public health challenges today involve deteriorating human capital.  To make the case, we summarize a number of indicators of overall wellbeing and document that the United States has reason for great concern regarding our deteriorated health status (e.g., highest rates of mental illness in the world, highest incarceration rate, deteriorating educational achievement).  We further argue that the next major era in public health will be informed by an emerging general theory in which genetic vulnerability interacts with exposure to toxic stress and trauma to produce the behavioral health problems that ultimately underlie many of our human capital challenges.  The biopsychosocial factors underpinning these conditions will be summarized, which begins to provide an integrative framework for understanding the etiology of these problems.  Additionally, the chronic health conditions that present the greatest challenges to our medical treatment systems are also importantly influenced by these underlying factors.  Prevention science has much to offer in strengthening our human capital both by reducing risk factors (e.g., child abuse rates, neighborhood violence) and increasing preventive factors (e.g., positive parenting,  supportive school environments).  Long term follow-up data indicate that many of the available preventive interventions could be characterized as behavioral vaccines that have long term laudatory impacts on overall health and wellbeing.  We conclude that the pressing needs of our failing human capital – particularly in light of international competition – should provide the impetus for rapidly accelerating the development of the infrastructure to fund and implement our prevention science and, much like the clean water and sewer systems that characterized the germ theory, will be the core elements of the next major era in public health. Current health reform efforts that include behavioral health explicitly and that focus on preventive interventions and population health indicators may provide essential impetus to realize the promise of our prevention science.