It’s not surprising that Dr. Sandy Escobar has potted yellow begonias in her office at Ravenswood Family Health Center (often referred to as “Ravenswood”) in East Palo Alto.
“I’ve started calling Fridays ‘Sunshine Day’ in our department,” she says. As clinical director of integrated behavioral health services, Escobar leads a team of two healthcare practitioners tasked with serving nearly 18,000 people a year—11,000 adults and 7,000 children. “By the end of the week, we need yellow,” she explains.
East Palo Alto sits across U.S. Highway 101 from Palo Alto and remained an unincorporated pocket of San Mateo County until 1983. With scarce public benefits and little commercialization, the area lacked basic infrastructure like a high school or supermarket for decades. In the early 1990's, it had the highest homicide rate in the country.
Around 2000, amid the roaring success of Silicon Valley, East Palo Alto began to gentrify; big-box stores and new housing cropped up, but that new development wasn't accessible to everyone. According to the most recent census, East Palo Alto’s median annual household income hovers around $49,000, while nearby Atherton registers $224,000. When Ravenswood opened its doors in 2001, it filled the gap left by a federally qualified health center that had shut down in 1996. Ravenswood is designed to reach uninsured and low‐income families facing barriers to accessing care.
Escobar learned the importance of advocacy at a young age. She was nine when her family moved from El Salvador to Los Angeles. “I completely remember that night,” she says. “Los Angeles looked huge to me. I don’t think I blinked.” She entered public school and started to learn English. As the eldest child and big sister to a sibling with special needs, Escobar became the family advocate.
She studied psychology as an undergraduate at UCLA and earned her doctorate at the California School of Professional Psychology in San Diego. Since 1995, Escobar has worked in mental health services for Los Angeles County, doing clinical supervision, implementing programs, and building partnerships. When her husband's job relocated them to the Bay Area in 2015, Escobar saw an exciting opportunity.
“I’d been doing more management than anything for the last 20 years and I wanted to get back to some clinical work,” she said of the move. “Given the amount of substance use and psychiatric needs I saw in my case load, I was most interested in places where mental and behavioral health sat alongside medical care.” Escobar was interested in East Palo Alto, where the population of nearly 30,000 is 65% Latinx and over 40% foreign-born. She took a position at Ravenswood in 2017 to oversee the department and treat patients.
The high level of trauma was apparent right away. Escobar met families living 10 people to a single bedroom, immigrants fleeing violence back home and facing discrimination in America, severely depressed mothers. She suspected issues like these existed throughout the community, but despite her department’s proximity to it, there were few instances in which someone who came in seeking medical treatment was referred for mental health services.
While approximately 50% of Ravenswood’s 90,000 patient visits last year were for primary care, only about 2% were for behavioral health. “In my family, we go to primary care and that’s where we start talking about everything else under the sun,” she says. “You don’t want to be entering a clinic that says ‘Mental Health Services’ in big blue letters. There’s a stigma.”
“The first step is education and identification,” Escobar says. She describes a common occurrence: families coming in for physical symptoms—a child who has tummy aches, for example, who doesn’t want to eat or go to school, or who can’t sleep. In conversation, it might come out that there was a recent lockdown at the school, a car accident, or siblings using drugs at home. “You would be surprised how few people make the connection between environmental factors and health,” she says. “Disconnection is a typical trauma response. You disconnect to survive.”
Eleven months into Escobar’s time at Ravenswood, she was approached by a colleague from pediatrics. Dr. Jaclyn Czaja told her about the Resilient Beginnings Collaborative (RBC), a two-year opportunity to receive $80,000 in funding and staff-wide training on childhood adversity led by the Center for Care Innovations, and made possible by Genentech.
RBC was a first-of-its-kind initiative, one that would place Ravenswood in a peer group of six other pediatric safety net clinics across the Bay Area. Together, the effort aimed to impact 50,000 kids, nearly a third of all young children eligible for Medi-Cal regionally. Escobar got excited. She saw RBC as an opportunity to bring together the work of multiple departments: behavioral health, pediatrics, and maternal health.
Ravenswood applied and was accepted. Their participation in RBC began last year. Escobar says her team is already feeling the results: referrals are up 25%; a new postpartum support group is in the works; and staff—approximately a third of whom come from low-income communities like East Palo Alto themselves—are increasingly aware of their own histories of trauma. They have access to the tailored resources and tools they need to cope.
When she reflects on the source of her own resilience, Escobar talks about her parents. “I’ve never seen them give up in anything they’ve ever done,” she says. She sees the same drive in many of her patients and works to remove whatever obstacles she can. “We don’t call it therapy,” she says, in an effort to sidestep the stigma. “We say, ‘Let’s chat, let’s talk.’ And then, ‘Let’s have another talk next week.’”
While families in need are now much more likely to get referrals for behavioral health services at Ravenswood, challenges remain. The volume of patients is high. If an individual is identified for care but the system is so inundated that no clinician is immediately available, the clinic must rely on patients to follow up. Given the complexity of patients’ lives, it’s often those most in need who fall through the cracks. With additional resources, Ravenswood can hire case managers to coordinate care for the most difficult cases, Escobar says.
“The antidote to trauma is connection,” Escobar says. “In an area with a very steep cost of living, at a time when we feel more and more politically divided, where fear is a common state of being for so many of our neighbors, where the technology being developed all around us is adding to our sense of isolation, Resilient Beginnings Collaborative is an effort to rebuild relationships. It’s incredibly powerful.”