Health as a Foundation for Social Justice and Racial Equity

Dr. Barbara C. Staggers, Senior Advisor on Adolescent Health for the California Children’s Trust, retired in 2019 as director of adolescent medicine at Children’s Hospital Oakland, where she also served as director of external affairs and community relations. She earned her B.A. in psychology from UC Berkeley, her M.D. from UC San Francisco, and a master’s in public health with a focus on health education from UC Berkeley. She completed her pediatric residency at Children’s Hospital Oakland and her fellowship in adolescent medicine at UCSF. Recipient of numerous national and state honors and awards, Dr. Staggers is a national authority on adolescents at risk, urban youth, youth of color, violence, and health care issues of multicultural societies. Dr. Staggers was also a physician consultant to the City of Berkeley’s Department of Public Health and spent 10 years as an adolescent specialist and director of school-based clinics for the Oakland Unified School District. In October 2020, colleagues and friends gathered in Oakland to celebrate Dr. Staggers and her decades of profoundly important work in adolescent health. Click here to view a video of the tribute.

Alex Briscoe, Principal of the California Children’s Trust, was appointed in 2009 director of the Alameda County Health Care Services Agency, where he led one of California’s largest public health systems, overseeing health and hospital systems, public health, behavioral health, and environmental health departments with an annual budget of $700 million and 6,200 FTE contracted and civil service staff. Prior to that, he directed the Chappell Hayes Health Center at McClymonds High School in West Oakland, a satellite outpatient center of Children’s Hospital and Research Center. Mr. Briscoe’s work has helped design the nexus of public health and public education. He has designed and administered mental health and physical health programs and services in child serving systems, including home visiting programs, programs for medically fragile children, and clinical and development programs in child welfare, juvenile justice, and early childhood settings. Mr. Briscoe has served on the Alameda County First Five Commission, The Alameda Alliance, and The Kaiser Commission on Medicaid and the Uninsured, as well as other public and private boards and commissions. Mr. Briscoe is a mental health practitioner specializing in adolescent services and youth development. He has specialized in Medicaid policy and administration, emergency medical services, youth voice and crisis counseling, and safety net design and administration. 

The California Children’s Trust (CCT) was founded to reinvent our state’s approach to children’s social, emotional, and developmental health. CCT is a statewide initiative that seeks to improve child well-being through policy and systems reform. Our work is grounded in and informed by the work of Dr. Barbara Staggers, who founded the first school-based health center in the nation at Fremont High School in East Oakland. Dr. Staggers works as the Senior Advisor on Adolescent Health for the Trust, and her groundbreaking work is foundational to our Framework for Solutions and our vision for Healing Centered Schools.

Alex Briscoe met Dr. Barbara Staggers 25 years ago, while he was a counselor at McClymonds High School in West Oakland. After school on a Friday, one of Briscoe’s students needed medical attention but didn’t know where to turn. Clinics were closed for the weekend, and after Briscoe had placed many fruitless calls trying to find a place for the student to go, someone said, “Call Dr. Barbara Staggers. She’ll see teens anytime.”

Then the director of adolescent medicine at Children’s Hospital Oakland, Dr. Staggers had already gained national attention for her transformative work with adolescents. The daughter of a doctor— her father was the first Black surgical sub-specialist trained by the United States Navy—Barbara Staggers did not always plan to be a doctor. In fact, she studied ballet from a young age, dancing professionally in her teens.

“Growing up, I always knew that I was valued, respected, and loved,” says Staggers, “by my parents and other strong mentors. I was listened to, and that stayed with me.”

The summer she was 18 and working as a camp counselor, her focus shifted from dance to medicine after she made two distressing observations.

“There was a 14-year-old in our summer camp program— I can close my eyes at 66 and still see this young woman today,” says Staggers. “One morning she got picked up by a man who was obviously her pimp, who said, ‘I need her today.’ I told him we couldn’t sign her out without the parents’ consent. I contacted the mother, who said, ‘Let her go. We need the money.’ I never saw that young woman again but I never forgot her.”

That same summer Staggers’ uncle, who was in his fifties, went to the ER with chest pains. “Anybody who knows anything knows a 50-year-old man with chest pains is probably having a heart attack unless it can be proved otherwise,” Staggers says. “My uncle died in the waiting room. Later the director of the hospital said, ‘If we had known his brother was a doctor, we would have treated him differently.’

“So that summer I learned: Who gets screwed? People of color. Who gets screwed the most? Teens of color. So I decided I wanted to be a medical doctor working with adolescents. And I wanted to become a national expert on adolescent medicine, which didn’t exist at that time.”

Staggers went to UC Berkeley to study psychology, then earned her medical degree at UCSF. Knowing she wanted to work with teens, she returned to Berkeley for her master’s in public health, then back to UCSF to complete a fellowship in adolescent medicine.

“The medical model had very little reality for the young people I saw,” she says. “When I sat for my adolescent boards, there wasn’t a single question on it that was relevant to the teens I was working with every day.”

Dr. Staggers has devoted her career to creating a new model of care for young people that is respectful, relevant to their lives, and centered on relationships. To meet young people where they were, she founded the first school-based health center in the nation at Fremont High School in Oakland.

A couple of years after their first meeting on that Friday afternoon, Dr. Staggers and Alex Briscoe founded another school-based health center, this time at Oakland’s McClymonds High School. The launch of this school-based health center in 1998 represented a new model of support for young people by taking advantage of MediCal reforms to children’s mental health financing, and eventually led to a 100 million dollar expansion of school health services with a variety of partners in Alameda County. (For more information on the Center for Healthy Schools and Communities at the Alameda County Health Care Services Agency, see the center’s website.)

Dr. Staggers and Briscoe sat down in late summer 2020 for a conversation about their long friendship and collaboration, and how Dr. Staggers’ work has impacted the field and the work the California Children’s Trust was created to do.

AB:  Before we begin, Barbara, I think it’s important to acknowledge to anyone reading this that I have known you for a long time, memorized your phone number when I was in my early twenties, and still call it weekly 25 years later. And I know I am not the only one who could say that…the vast majority of whom are Black and Brown.

You have taught me and many others about the power of love, acceptance, and humility. You once said to me and the late great Bert Lubin that you pick your white boys carefully. The clinics we worked in together were nurtured and led—still are—by people of color and adult allies with lived experience. I count these amazing leaders, and many others I don’t know, as your most impressive and important accomplishment.

One of the things you have offered me is a reflection of the beauty and wisdom of the young people in the communities we have worked in together—a fierce loyalty, and just as fierce a commitment to listening and not judging.

You teach and model that the heart of all of this work (healing, justice) is the primacy of relationship. And what an essential and abiding opportunity relationships are to the health and welfare of young people—and how deeply we can learn from and honor how much young people show up for each other.

You have for me. And I like to think we learned this, at least to some degree, from watching how young people, even in the most difficult of circumstances, survive and thrive based on their connections with each other and their adult allies.  I know we share a belief that we can only be healed individually, and as a culture, by investing in the depth and consistency of our relationships. I know we both credit the young people we have worked with for the depth of the love and trust we have with each other, and I know this to be true for so many of the people you have worked with.

So while I have learned a lot about Medicaid and public systems since you responded to my frantic call that early Friday evening 25 years ago, the thing I have learned most from and about you is to listen, celebrate, honor, and laugh at life’s challenges—they too will pass, and they don’t define us. Bigger and better things do.

Q: So let’s get down to it. What do adolescents need?

To be cared about. You can’t have them question whether you care about them.

BS: Adolescents need someone who cares about them. You don’t like what they do all the time but you have to have love for them.  You can’t have them question whether you care about them. Separate the behavior from the person. If we look at just the behavior, we make all the wrong assumptions. This is actually a really important way that racial bias shows up, and also why we have always struggled with the term “behavioral health.” Young people aren’t the choices they make.  Often, all of the information they have to make choices with is either non-existent or bad.

AB:  I so agree that young people make great choices when given good information. That’s how you trained us: You don’t have to like what they do but you’ve got to love them. And our task as treating professionals and allies was to be in a relationship, know the origins of reactions to kids’ behaviors, and not stop caring.  Even when it’s hard.

BS: That’s how they build their own relationships. By knowing people who have demonstrated what it means to care. For some young people, they only know hard. If you can’t stay with them when it’s hard then you’re not really showing you care.

AB: Yes.

BS: If you can’t trust the people who are supposed to care about you, where do you go? What do you do? You find someone who seems to care about you. And you might not know the rules but this is the door to whatever comes next. And the world may be giving you mixed messages about your value or your future, so finding someone and believing they care about you is basically the hope and the danger of adolescence. Young people are looking for people to trust, and this has to come first.

AB:  It is a therapeutic maxim that we are almost always hurt in the context of relationship, and can only be healed in it.  Healing, non-judgmental relationships can be very scarce for young people because sometimes their behavior can appear to be so extreme, particularly where there are race or class barriers between allies and young people. One of your teachings, Barbara, was about staying in relationship even when a young person’s behavior feels unsafe— it’s important for the young person to know there’s an adult who cares, who wants the best for them, and who isn’t leaving.  So often for white people doing this work this means holding and not acting out of your own discomfort, need, or fear.  One of my favorite ways you taught me this was simply by saying my name in the form of a question: “Alex?” It was the most kind and loving (and effective) way of checking and teaching all at once.

BS: A question we all must answer all the time is: Where do you go to get love? Where do you go to get grounded? That’s a hard question. This is something people struggle with still, young and old.

Q: What makes a school-based health center work?

Tailor it to the needs of the community.

BS: It has to be tailored to the needs of the community it’s in. You can’t skip that part.  Even if you know what someone is going to say, you have to ask and listen. Everyone is important, and you can’t fake it.

Everyone who’s a major player needs to be at the table during the planning phase: the people you’re going to serve and all of the stakeholders— the parks and rec department, the juvenile justice system, law enforcement. You ask: What are the issues in your community? What are the needs? And then you look at your data to see what the data shows that the issues are: pregnancy, stress, depression, all of the above? One size does not fit all.  Young people and the community the school serves need to see their voice reflected in what happens—health care is built on alliance with your patient. You can’t have that if you don’t know them, and knowing someone requires that you ask and then listen to what they have to say.

AB: I love that, Barbara, and I want to try to name that. Even when you know the answer, you still have to ask.

BS: Yes. I remember being in a town in northern California where they’d built a million-dollar facility for teens that no one was going to. The mayor asked his son why teens weren’t using it, and his son said, You never asked us where you should put it. Teens won’t go where you put it. If you don’t ask, you won’t know. You have to ask.

Schools are usually neutral territory. In a world where communities have reason not to trust people in authority, schools can still be a center for community—but they have to be respectful, open, supportive, kind…and available. Health care is what holds all the systems together in that neutral territory. Health is something we all want for everyone.

AB: You knew that bringing services to schools, the school-health frame, would be a way to bring the fragmented child serving systems together around a concept they could all align around.

BS: That’s right. It’s a way to bring in all the stakeholders who impact kids’ lives. Schools are neutral territory, they’re accessible, and usually (not always) they are seen by Black and Brown people as being on their team. But the goal for schools has to be about more than test scores or college admissions.

AB: Right. And the mortar to hold all these systems together while leveraging the neutral ground of schools is health care. The health care frame is respectful, it’s inquiry based, it’s racially informed, and it includes a focus on racial justice….at least it can in the way you teach it.

BS: The pitfall of the traditional medical model is it’s not equity-based so dealing with that reality is very important. So you’ve got to have the advice of the right stakeholders. People you trust. People who walk the talk. Whenever possible, people who look like the communities they serve.  It can and must be done across racial lines, but it’s really important for kids to see people who look like them in positions of leadership.

Kids can tell when you love them. When you care about them. When you aren’t scared of them. They will test you, to see if you are real. They want to see if you will stay in it with them.  And that’s the advice I would offer anyone who wants to connect with young people. Don’t give up. Don’t stop asking and listening. Don’t force it but don’t go away either. Like you and me, young people want to be seen, heard, and understood. No matter who you are, if you are willing to have a relationship with a kid, and not just on the terms you dictate, good things can happen.

Inquiry-based racial justice, relationship-based health care

AB: Right. People who ask good questions and wait for the answer. Wish that wasn’t so rare.

Barbara, you walked into Fremont High in the 1980’s knowing a bunch of things instinctually. It feels like so much of our work at the Trust is trying to scale these lessons and imbue them in how we fund and administer supports for young people across systems—using the principles you pioneered in a broader systems frame.

And I think this frame of relationship-centered work is the essential teaching. I can remember walking the halls of McClymonds or shooting jump shots with a young person for months, even years, before that young person decided I was trustworthy. That feels right and proper in retrospect.

There are now 28 federally qualified health centers and 200 other programs in schools in Alameda County alone. We took those lessons about inquiry-based racial justice and relationship-based health care and tried to use them to bend, perhaps break, the medical model.

BS: You have to walk your talk. That’s important. What you say, you’ve got to prove it and do it. You can’t just say the right thing. You have to live it and prove it. This is something that happens over time, and it takes adults who don’t get scared away easily, are willing to work through their own stuff, reserve judgment, aren’t afraid to be wrong, and admit it quickly.

AB: Yes. Adolescent health work is self-selecting. I wish it didn’t matter so much but there is a type of person who is accessible to teens and likes the work, and others who aren’t. What makes it work? What makes a person accessible to young people?

BS: You have to be open, honest, trusting. You don’t have to know it all because you can’t know it all. You have to admit when you make mistakes. It’s ok not to know. You have to say I’ll figure it out with help. Model that combination of confidence and vulnerability. And you can’t make assumptions. If you think you know something without asking—stop. Ask. Assuming and judging are the same thing and it is a big transgression in young people’s eyes.

Q: How did the first school-based health center come about?

The beginning of a movement: putting services where kids are

AB: Fremont High School Health Center was the first school-based health center in the nation. So let’s talk about how it came to be.

BS: The Stuart Foundation approached me, Planned Parenthood, and some of our health care colleagues. They wanted to fund a health clinic. As we were in the planning stages, the newspaper wrote a story, and they called it “Sex Clinic to Open at Fremont High School.” Our parent advisory committee asked the paper to retract the story because it was not a sex clinic.

The parents told the paper that the clinic was delivering basic health care to the kids, which is what the parents had asked for. So the parents told the newspaper to keep its nose out of our school! We were providing adolescent health services. Parents later decided they wanted contraception to be part of it, but initially they did not. I always remembered that as a problem in this work. That things get framed in ways that don’t reflect what actually happened, or the voice of the people who are most impacted. Reproductive health is really important to young people, and it’s one of the core services in adolescent health. But sex is just a behavior. It’s more interesting to adults than it is to kids. Yes, pregnancy prevention, STD treatment and prevention matter, but sex happens in relationships.  Sexual acting out is almost always a function of broken relationships, not some uncontrollable teen thing. Had the paper called it a relationship clinic it would have been easier to handle.

AB: That was the beginning of a movement—putting services where kids are, and acknowledging the reality that if you want a teen clinic that no one comes to, put police or parents in the waiting room, or call it a sex clinic. It has to be about sanctuary.  A place to go where people are looking out for you and you can count on them keeping what you bring private.  There’s something about the protected interaction of teens and their adult allies who aren’t their parents that is the essence of adolescent health work.

AB: When I first started training under you, Barbara, I was reading a lot of Eric Erickson, the famous therapist, and he had this term that I loved: individuation. He was referencing the natural process of separating yourself from your primary parent group and becoming a person.   In retrospect I see now how limited some of his writing was from a racial justice perspective, but I do think his understanding of young adulthood was a worthy concept. He said that taking risks and living in the world is part of understanding yourself as a person—how this is both awesome and dangerous. Some of the communities you have worked in have such a small margin for error for young people.

BS: Yes. You make a mistake, you’re dead.

AB: And how important accessible adult allies are—allies who actually know some stuff that’s real and useful about how to build and stay in relationship—and not lessons or checklists, but demonstrated behaviors and actions that include restraint, and invitation to contribute.

BS: It’s about relationships and the teaching of them.  You can watch young people adopt the strategies and style of the adult relationships in their life. Good or bad. Adolescent medicine is at least in part about raising awareness for young people, helping them develop a reflective and adaptive capacity in a world that isn’t always safe for them—an awareness of how the world they live in is impacting them, and offering or constraining their choices.

AB: There would have been no clinic at McClymonds if young people hadn’t asked for it, demanded it, learned they deserved it, and grew it and cherished it. And there wouldn’t have been a clinic at Fremont if you hadn’t shown up there and used your extraordinary skill and charisma to connect with young people. Alliance presupposes it all.

Q: Why is mentorship important?

Creating pathways of success

AB: Let’s talk a little about the people you’ve mentored. So many leading pediatricians of color trained under you and worked in the clinics you founded and directed— some of the leading pediatricians in America: Dr. Dayna Long, Dr. Rhea Boyd, numerous others. FACES for the Future, which you founded, has a very direct focus on training pediatric and adolescent health practitioners of color. And later you founded the Chances Program for adolescents. Talk about that history.

Seeing young people as the workforce of the future

BS: We wanted to create a pathway for success. Under-represented minority youth said, Get me off the streets. I need something to do. I want to become you. We said Ok, let’s design a program. We used the same principles in The Chance Program as we did in FACES. And now there are a lot of other mentoring programs using the same principles.

AB: It reminds me how different health care is from law enforcement. If you do healthcare long enough you see the people you serve not as sick and broken but as beautiful and brilliant. You were the blood and guts doctor of teens in Oakland in the 80s when homicide became the leading cause of death for young people. And you didn’t see young people as pathological or violent or bad. You saw them as the workforce of the future, and you started creating internships for them in the hospitals. The health frame helps us see young people as the solution, not as the problem. I saw that when I was working with you—you saw young people as potential. You really walked that talk. You made pathways for them.

BS: That’s what I learned from them. I learned that each and every one was a beautiful individual, and I wanted them alive and thriving. I wanted to see them succeed and get on with their lives. That was the most important thing for me, and they reaffirmed it every day.

AB: Yes. If you ask young people good questions and listen to what they say, you learn from them and you can’t help but acknowledge their wisdom and intelligence. If you can’t do that, you’re not alive.

BS: I did it for 35 years so obviously I loved my work.

The California Children’s Trust: Doing for the System What We Did for Schools

AB: Something is going on with kids.  I know you have been in this work for a long time and seen a lot of young people dealing with difficult circumstances.  You know the data we cite at The Trust. What you do you think is going on?

BS: Young people feel helpless and hopeless. And they seem to know it in new and deeper ways. I think it’s a combination of factors as is always the case, but the solution is still relationship. If you feel like there is nobody out there you can feel grounded with, where do you go? When you feel like there’s not any hope, and you aren’t worth anything, it’s easy to kill yourself or take another life.  

AB: One of the reflections I have, Barbara, is that despite the amazing work you have done, the reality is that most kids still get so little, and far too often the support they get is too late and maybe even the wrong kind. The type of support we talked about earlier—unconditional love and caring even after they screw up—most kids don’t get that.

BS: That’s why you started CCT. You’re building the relationships in a broad sense, and tying the actual architecture of the system to these concepts.

AB: Right. Not the exception or the demonstration, but the intent and purpose.

BS: You’re saying it’s not one stop or one size fits all. You’re taking the time to ask the questions to get the data so you know what to do, what will work. You’ve brought all the stakeholders to the table. You’re grounded in the work I’ve done all my life.  And you are talking about how to scale it, maybe not by building a million-dollar clinic in every school, but by developing a set of principles about how to support the social and emotional health of children. I love what the Trust is doing.

AB: Thanks, Barbara. We’re trying to do for the system what we and others have done for a school. To bring that frame of relationship and unconditional love, structured in terms of what actually happens in the lives of kids, and acknowledge the reality that despite the incredible example you and others have built, it’s not actually happening. We are all wringing our hands at a problem, and mistaking the critique for the solution. We know the solution. It’s the work that you did. We have to pay for it and scale it.

BS: That’s right. And you’ve got to have vision and you have to have dreams. If you stop dreaming, you give up.

AB: The Trust is McClymonds at the systems level.

BS: That’s right. It is.

Health as a foundation for social justice and racial equity

AB: We know what young people want and we’ve learned how essential schools are, and we know the key elements of success: relationship-based; health care as the actor to pull together a fragmented support system; unconditional love; a trusting alliance. The Trust is trying to do this work at scale because things got worse and we didn’t get it done. As much as people like to do tours of the school clinics we started, the reality is less than 5% of kids on Medicaid get anything at all. It’s got to be confronted at some point.

BS: Our health care system is all about pay first, face it later: How are you going to pay for this visit? You can’t say to a kid: I can’t see you. That sends a message to that kid.

AB: That’s part of the lesson of your career: health as a foundation for social justice and racial equity but not as a medical model. This conversation makes me remember the smell of those hallways. I remember taking you into that old vocational education space and saying, “This is going to be a clinic!”

BS: You were building your dreams. I was fortunate that I got to build my dreams in different ways, different places. Definitely one size does not fit all.

AB: When I became Alameda County Health Director and we were building a new juvenile hall I called you, Barbara. We basically built McClymonds in juvenile hall, and then used it to empty it. The day we opened that clinic there were 418 kids in juvenile hall. There are 60 there today. It was the same principles of system change.

And as proud as I am of those efforts and the many people who contributed to them, I know we didn’t do them well enough, and there are massive problems, and that’s why in some ways we’re coming full circle, Barbara. We’ve got to go back to schools and get it right.

BS: Schools are apolitical, or should be. They have to become a sanctuary. They have to be grounded in relationship. They have to honor and celebrate struggle. They have to be caring.  They have to be fun.

AB: That comment you made about schools as neutral ground is so important. As difficult as schools are, they can be safe spaces. Get the cops out of them, center relationship and healing.  It can and must be done.

BS: And don’t forget—older teens are great at working with younger teens. You can build up the pipeline.

AB:  Thanks for raising that. The whole purpose of our healing-centered schools proposal is to make them youth-driven and youth-friendly. Populate them with caring adults. Make them restorative and healing—but focus on young people as the solution, not the problem.  We’re coming full circle to try to bring back to schools what it will take to make them healing-centered.

BS: Yes, we are, my friend. And now we know how to do it.