Dr. Flojuane Cofer-ACEs, Race, and Health Equity

Summary

Dr. Flojuane Cofer argues that adverse childhood experiences (ACEs) and their health effects cannot be understood apart from race, racism, and the conditions of the communities where people live. ACEs do not happen in isolation, and a broad “they affect everyone” framing can obscure unequal exposure and unequal access to protection and resources.

Main ideas

• Early experiences shape later health and behavior. Cofer uses Anakin Skywalker’s life as an illustration: childhood trauma and separation coexist with protective relationships and opportunities, while later violence and instability compound risk. People are often encountered partway through their lives and judged by asking, “What’s wrong with you?” rather than “What happened to you?” or “How can we prevent harm?” The latter questions better support prevention.
• ACEs are associated with many adult health outcomes. Cofer describes how the original ACE research emerged from observations in an obesity clinic: participants’ progress could be disrupted when unwanted attention made them feel unsafe. ACEs include abuse, neglect, and household dysfunction before age 18. The research found a dose-response pattern, with more ACEs associated with a higher likelihood of various physical, behavioral, and mental-health problems.
• The original ACE research did not represent everyone equally. The study drew on about 17,000 people insured through Kaiser in 1998. This population was disproportionately white, employed, college-educated, and middle-income. Cofer notes that Black, Latino, Native American, Asian and Pacific Islander, immigrant, uninsured, homeless, and child populations were missing or inadequately represented.
• Traditional ACE measures leave out important experiences. Examples Cofer says deserve attention include a child’s own incarceration or juvenile-justice involvement, foster care, deportation, homelessness, school suspension or expulsion, and bullying. These experiences are not distributed evenly across groups.
• Community trauma matters alongside household trauma. Cofer discusses adverse community experiences such as natural disasters, community violence, concentrated poverty, discriminatory policies, and the vilification of people’s identities. Household and community adversity can interact, potentially producing effects greater than either alone.
• Toxic stress affects the body and brain. Cofer distinguishes short-lived positive stress and manageable, tolerable stress from toxic stress, which involves extreme, frequent, or prolonged activation of the stress response, particularly without support or resolution. She argues that the body is not designed to remain in fight-or-flight mode, and that prolonged stress can affect brain function and accelerate biological aging.
• Race and racism shape exposure to stress and health risks. Cofer describes how social identities intersect: people who share a racial identity may experience racism differently depending on other aspects of their lives. She also explains implicit bias as unconscious attitudes shaped by socialization. These attitudes may not match a person’s stated beliefs but can still influence decisions and perceptions.
• Racism operates at multiple levels:
  • Personally mediated racism: Direct differential treatment.
  • Cultural racism: Norms that value some groups, identities, or ways of speaking over others.
  • Internalized racism: People absorbing negative messages about their own group.
  • Institutional racism: Policies and practices that reproduce inequities, even when individual actors do not intend to do so.
• Historical policies can have lasting effects. Cofer uses redlining to illustrate how housing policy shaped where people could live and where public and private investment flowed. She connects this history to continuing economic and educational inequities, and describes the war on drugs as another example of institutionalized bias whose enforcement disproportionately harmed Black and Latino communities.
• Anti-Blackness and proximity to whiteness must also be examined. Cofer cautions that “people of color” is a broad category that can obscure differences among groups and the persistence of anti-Blackness, including within communities of color.
• Equity requires changing structures, not only helping individuals adapt. Cofer contrasts removing barriers with merely “stacking boxes” to compensate for them. Public-health organizations, she argues, should identify and dismantle structural obstacles and make equitable practices part of how institutions operate—not dependent on a single committed leader.

Practical steps for organizations

• Address institutional and historical causes of trauma.

  • Name the role of institutional racism rather than remaining silent.
  • Treat public health as responsible for leading and preventing harm, not only commenting after it occurs.
  • Model equitable practices within your own organization.

• Make effective practices durable.

  • Embed equity and trauma-informed practices in policies, procedures, and organizational documents.
  • Ensure the work continues through leadership and staff turnover.

• Examine internal organizational data and practices.

  • Look at who is represented in leadership and whether staff from marginalized groups leave at similar rates.
  • Treat underrepresentation at senior levels or a lack of advancement opportunities as possible signs of a pipeline or workplace problem.
  • Notice whether staff from marginalized groups are expected to do unpaid mentoring or diversity work.
  • Ask whether new ideas and different approaches are genuinely welcome.

• Build accountable partnerships with communities.

  • Partner with people from communities facing inequity and compensate them for their expertise.
  • Recruit and hire from those communities, build local capacity, and leave communities better positioned to continue the work.
  • Focus on removing structural barriers rather than claiming to “empower” communities or imposing outside solutions.

• Change hiring and advancement practices.

  • Avoid hiring only people who resemble existing staff or share their educational background.
  • Recognize community experience as valuable expertise; do not require degrees when they are not essential to the work.
  • Revise job descriptions and create alternative pathways into roles.
  • Provide meaningful mentoring and opportunities, rather than limiting new staff to low-level tasks and then judging them as unprepared.

• Develop shared understanding and language.

  • Expect equity work to be uncomfortable and ongoing; a single conference session cannot undo socialization.
  • Use tools such as Harvard’s Implicit Association Test and shared reading or discussion to help open dialogue and identify bias.

Speakers and sources mentioned

Speakers

• Dr. Flojuane Cofer — Keynote speaker; epidemiologist and senior director of policy at Public Health Advocates.
• Unnamed event host/introducer — Introduces Cofer and describes the county’s ACEs and equity work.

Sources, examples, and references cited

• The ACE study and its Kaiser population.
• Prevention Institute — Referenced in connection with adverse community experiences.
• Star Wars, including Anakin Skywalker, Obi-Wan Kenobi, and Darth Vader — Used as an illustrative life-course example.
• George Lucas — Mentioned in connection with the Star Wars character.
• A Time to Kill — Referenced in an analogy about representation.
• The Washington Post — Cited for a headline about the Las Vegas shooter, Steven Paddock.
• Cleveland.com — Cited for coverage of Tamir Rice.
• Federal Housing Authority and historical redlining practices.
• Harry Anslinger, the Federal Bureau of Narcotics, and the DEA — Cited in discussing the history of drug policy.
• New York Academy of Medicine (1944) and the Schafer Commission (1972) — Mentioned in the discussion of marijuana policy.
• Harvard’s Implicit Association Test — Recommended as a tool for examining implicit bias.
• Advanced Peace — Mentioned as an example of a newer violence-reduction approach.