'Upstreamism': Your zip code affects your health as much as genetics
Upstreamism advocate Rishi Manchanda calls us to understand health not as a "personal responsibility" but a "common good."
- Upstreamism tasks health care professionals to combat unhealthy social and cultural influences that exist outside — or upstream — of medical facilities.
- Patients from low-income neighborhoods are most at risk of negative health impacts.
- Thankfully, health care professionals are not alone. Upstreamism is increasingly part of our cultural consciousness.
If you encounter the word "miasma" today, it's probably in reference to the worst level of a popular video game. But as late as the 19th century, medical science treated such "bad air" seriously. Under the purview of miasma theory, doctors believed that epidemics of diseases such as cholera and bubonic plague originated from noxious air wafting from decaying, rotting flesh.
Enter John Snow. Mapping an 1854 outbreak of cholera, Snow discovered that the afflicted shared a common environmental link. They all secured water from a pump on Broad Street in Soho, London. Snow theorized it was the water, not the miasmatic air, that caused the outbreak. He removed the pump's handle, nullified the spread of the disease, and proved his theory accurate.
Because of this, Snow is widely considered the father of epidemiology. Michael J. Dowling, president and CEO of Northwell Health, offers an additional honorific. He cites Snow as a "classic upstreamist," one whose example is important to understanding our struggles with upstreamism today.
What is upstreamism?
Upstreamism is a call for health care professionals to recognize that many of the determinants affecting a patient's health exist outside the medical facility — that is, upstream of it.
A clinician can prescribe medicine or offer advice when the patient is in their practice, but consider how much time the average person spends in a hospital and the like. Very little. Instead, the vast majority of a patient's life is spent upstream, in their environment, where many mental and physical health issues can manifest and potentially worsen.
If a health care professional is to be an upstreamist, they must equip themselves to assess and address these social and cultural determinants together with a patient's symptoms.
Rishi Manchanda, founder of HealthBegins and upstreamism advocate, says that "one's zip code matters more than your genetic code." In fact, he points out, epigenetics shows us that our zip codes can shape our genetic codes.
In his TED talk, Manchanda illustrates upstreamism with an anecdote about a patient named Veronica. Veronica suffered chronic, debilitating headaches. She had visited emergency rooms three times before trying Manchanda's clinic. The previous doctors looked at Veronica's symptoms in isolation, saw nothing wrong, and prescribed standard pain medication.
He measured the same vital signs, got the same results, but asked an additional question: what were her living conditions like? Turns out, her living conditions weren't ideal. Her housing had mold, water leaks, and cockroaches. Manchanda theorized that her condition may be the result of an allergic reaction to the mold, a diagnosis the others missed because they only considered Veronica's symptoms in isolation. They forgot to look upstream.
Swimming against the social current?
Volunteers beautify a park in Bowie, MD, as part of a three-year project to repair low-income neighborhoods in the county. (Photo: Staff Sgt. Alexandre Montes/U.S. Air Force)
Like an actual river, a patient's upstream environment doesn't flow in a straight line. In lieu of springs, streams, headwaters, and tributaries, a patient's constitutional watershed contains their social environment, their physical environment, their economic status, their individual lifestyle, and their access to care.
As a result, people living in low-income neighborhoods face far more negative social and cultural health influences than those living in wealthier areas. Patients from such environments are less likely to have access to pollutant-free water, full-service grocery stores and farmers markets, and parks and playgrounds. The stress of such environments leads to higher rates of depression, unresponsive parenting practices, and even increased rates of mortality.
"If you're living in a very, very good neighborhood, […] you will live years longer than the person who lives in a very, very poor area, in general," Dowling said in an interview. "So if I want to improve your health, I've got to make sure that I have doctors, and nurses, etc., to provide medical care to you. But I've also got to figure out how to work on all of these other things."
Mapping the upstream
The challenges of upstreamism would be daunting to health care professionals if they had to face them alone. However, we are in the midst of social changes that will make upstreamism viable. One of those changes is an always connected world where new information is available quickly.
Going back to Veronica's story, Manchanda didn't solve the problem alone. He connected her with a community health worker, and the partnership paid off. The community worker found mold, a strain Veronica was allergic to. Once her home conditions improved, Veronica's quality of life did as well. Manchanda inadvertently helped one of her sons, too, as his asthma was exacerbated by the same mold.
"If we're all able to do this work, doctors and healthcare systems, payers and all of us together, we'll realize something about health. Health is not just a personal responsibility or phenomenon. Health is a common good," Manchanda said in his TED talk.
Beyond search engines, technology companies are making a big push for health care. The tools and innovations they develop could streamline the mapping of a patient's upstream environment. For example, devices like smartphones and Fitbits may allow patients to generate their own health records, offering doctors a proactive, up-to-date account of a patient's environment. The growing ubiquity of such devices will also allow doctors to perform virtual health visits, giving them easy access to patients and their live-in environment.
Finally, many health care professionals and organizations are heeding the upstreamist call to use their voices to advocate for changes to harmful social influences. As part of the Greater New York Hospital Association, Northwell Health has supported actions to curb gun violence in the United States. They advocate for, among other steps, a renewed ban on assault rifles, enhanced background checks, and permitting the CDC and NIH to conduct research on gun violence.
"[G]un violence isn't just a national tragedy, it's also a public health crisis," writes Dowling in his book Health Care Reboot.
This brings us back to John Snow. If he hadn't looked to the environment, looked upstream, he may have missed a solution that saved people's lives. The problems facing upstreamists today may require solutions more taxing than removing a water pump handle. But through technology and changes in social attitudes, they are manageable and can have a lasting impact on health care.
The main bioactive compound in catnip seems to protect cats from mosquitoes. It might protect humans, too.
- For centuries, humans have observed that cats exhibit strange behaviors when exposed to catnip and silver vine.
- A new study examined how the main bioactive compound in these plants affects cats' opioid systems and protects them against mosquito bites.
- The findings suggest that the compound nepetalactol could be used to develop new mosquito repellents for humans.
Nepeta cataria, commonly known as catnip
Johann Georg Sturm (Painter: Jacob Sturm) via WikiPedia/Public Domain<p>In the study, researchers from Iwate University in Japan exposed nepetalactol-laced paper to different types of felids, including domestic and feral cats, a leopard, two jaguars and two lynx. The team also exposed nepetalactol to dogs and mice, but only the cats elicited the expected behavioral response.</p><p>To find out why cats react uniquely to nepetalactol, the researchers measured the animals' endorphin levels before and after they were exposed to the substance. The results showed that nepetalactol raised endorphin levels in cats.</p><p>But when cats were given drugs that blocked opioid receptors, their endorphin levels didn't rise, and their behavior didn't change. This suggests that cats' "μ-opioid system is stimulated by an increase in endogenous β-endorphin secretion when olfactory neurons are activated by these iridoids," the team wrote.</p>
Nepetalactol as a mosquito repellent<p>To test the efficacy of nepetalactol as a mosquito repellant, the researchers anesthetized two groups of cats. For one group, the researchers applied nepetalactol to the cats' heads. The other group was left untreated to serve as a control. The researchers then exposed the cats to Asian tiger mosquitos and counted the number of times the insects bit each group.</p><p>The results showed that the group treated with nepetalactol was much less likely to get bitten, sometimes by as much as 50 percent. The same proved true in a "more natural" experiment, in which cats were allowed to rub their faces on the plants themselves.</p><p style="margin-left: 20px;">"This is convincing evidence that the characteristic rubbing and rolling response functions to transfer plant chemicals that provide mosquito repellency to cats," the team wrote.</p>
The world's deadliest animal<p>While the researchers don't fully understand why nepetalactol activates the μ-opioid system in cats, they think the compound could help humans avoid mosquito bites. After all, some of the study contributors have applied for a patent covering the use of nepetalactol as an insect repellent. Gizmodo <a href="https://gizmodo.com/cats-love-catnip-because-it-protects-them-from-mosquito-1846092518" target="_blank" rel="noopener noreferrer">reports</a> that the researchers even tried applying the compound to their arms, which seemed to prevent mosquito bites.</p><p>For thousands of years, humans have aimed to protect themselves from mosquitos. The Egyptian queen Cleopatra was said to sleep surrounded by a mosquito net. The Romans used vinegar mixtures. And Mississippians turned to the American beautyberry plant. </p><p>Today, DEET is the most widely used mosquito repellent, but it's slightly toxic and can cause side effects, including seizures, though rarely. Developing better mosquito repellents could save many lives. The World Mosquito Program <a href="https://www.worldmosquitoprogram.org/en/learn/mosquito-borne-diseases#:~:text=Nearly%20700%20million%20people%20contract,more%20than%20one%20million%20deaths." target="_blank">reports</a> that mosquito-borne illnesses like malaria and yellow fever affect more than 700 million annually and kill approximately one million. </p>
A unique exoplanet without clouds or haze was found by astrophysicists from Harvard and Smithsonian.
- Astronomers from Harvard and Smithsonian find a very rare "hot Jupiter" exoplanet without clouds or haze.
- Such planets were formed differently from others and offer unique research opportunities.
- Only one other such exoplanet was found previously.
Munazza Alam – a graduate student at the Center for Astrophysics | Harvard & Smithsonian.
Credit: Jackie Faherty
Jupiter's Colorful Cloud Bands Studied by Spacecraft<span style="display:block;position:relative;padding-top:56.25%;" class="rm-shortcode" data-rm-shortcode-id="8a72dfe5b407b584cf867852c36211dc"><iframe type="lazy-iframe" data-runner-src="https://www.youtube.com/embed/GzUzCesfVuw?rel=0" width="100%" height="auto" frameborder="0" scrolling="no" style="position:absolute;top:0;left:0;width:100%;height:100%;"></iframe></span>
People often make a killing in stocks, but what else do people buy in hopes of selling for a fortune?
- Outside of stocks and bonds, some people make money investing in collectibles and make a fair amount on them.
- One stamp even sold for a billion times its face value.
- The extreme dependence on future collectability limits the potential of most of these opportunities.
Pokémon Cards<iframe width="730" height="430" src="https://www.youtube.com/embed/hVUmTaSoB5Y" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen></iframe><p> For those who weren't content to catch them all in a video game came a trading card game where you could collect them all. Some classic cards have gained tremendous stature among collectors and Pokéfanatics and sell for extremely high prices. </p><p> An older card featuring Charizard, a fire breathing dragon, regularly sells for thousands <a href="https://www.lifesuccessfully.com/gaming-articles/the-most-wanted-pokemon-cards-charizard#/" target="_blank" rel="noopener noreferrer">online</a>. Given that the card could be purchased for a couple of dollars in 1999, this is quite the return. A particular pack of the cards, which cost $5 in 2003, now sells for $650, one hundred and thirty times the original asking <a href="https://adamrybko.medium.com/stocks-or-pokemon-cards-an-introduction-to-alternative-investing-32fe499083c4" target="_blank" rel="noopener noreferrer">price</a>. </p><p> Of course, not every card will fetch these high prices. Buying cards as an investment is tricky. You have to essentially guess at which cards will be considered highly valuable at a later date and will be unable to collect any dividend before selling them.</p><p> Furthermore, you have to presume that people will be collecting the cards years after buying them. While Pokémon has remained popular, it is a bit of an outlier in terms of enduring success.</p>
Shoes<p> People from all walks of life, from skateboarders to the First Lady of the <a href="https://www.rappler.com/newsbreak/in-depth/imelda-marcos-shoes-mixed-legacy" target="_blank" rel="noopener noreferrer">Philippines</a>, enjoy collecting shoes. An entire subculture exists for people interested in collecting sneakers, and some people make quite a profit in it.</p><p> The Nike SB Dunk Low Reese Forbes Denims, priced initially at $65 in 2002, are commonly valued in the thousands of dollars now. The Nike Air Jordan 1 Retro High x Off White "Chicago" shoe sold for $190 a mere four years ago, but now sells for $4000 a <a href="https://sixfiguresneakerhead.com/sneaker-model-return-alternative-investment-stock-x-reseller/" target="_blank" rel="noopener noreferrer">pair</a>. </p><p> A <a href="https://www.huffpost.com/entry/sneakers-good-investment_n_5bd1f5ebe4b0d38b588143ee?guccounter=1&guce_referrer=aHR0cHM6Ly93d3cuZ29vZ2xlLmNvbS8&guce_referrer_sig=AQAAALOu0F9zs5DBHHOIjMgHOZR6K88W3rZkyD3ftBMz2nzlHfoxD4MS2Iz1vF3H-a4_xzOWIIrsJyv76Gj6xwUXaRIRdjq7M2m7I6-lxihWIcEfs7F9PgOwnx82JXPfXmWL7-RQlNUufOyvd8V6TCzMEYrEjzMXVU77IWk9MjOEtsln" target="_blank" rel="noopener noreferrer">Huffington Post</a> article points out that most of these shoes offered better returns than gold over the same period. The same article quotes YouTube personality <a href="https://www.youtube.com/user/mrFOAMERSIMPSON" target="_blank" rel="noopener noreferrer">Mr. Foamer Simpson</a> and his explanation of the difficulties of making money on shoes:</p><p style="margin-left: 20px;"> "There's a guessing game or element of unpredictability that makes it exciting for some collectors. With sneakers, you kind of never know. Sure, you know what sneakers are more limited or which ones were harder to get, but even with that, it fluctuates a lot. A sneaker that was very valuable two years ago might all of a sudden crash and no longer be valuable."</p>
Toys of all kinds<iframe width="730" height="430" src="https://www.youtube.com/embed/0uYnj1i1EQw" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen></iframe><p> If there's one thing everybody loves, it's what they loved when they were children. That often translates into old and rare toys fetching insane prices at auction.</p><p> Beanie Babies, those little stuffed animals from the 90s, once sold at a price of thousands of dollars <a href="https://www.thefiscaltimes.com/2015/03/02/How-Great-Beanie-Baby-Bubble-Went-Bust" target="_blank" rel="noopener noreferrer">online</a>, not bad considering they sold for $5. Lego sets, particularly those featuring well-known franchises like Star Wars, can sell for hundreds of dollars <a href="https://finance.yahoo.com/news/20-geeky-collectibles-could-millions-201624881.html" target="_blank" rel="noopener noreferrer">online</a>. </p><p> As with Pokémon cards, the success stories are dependent on what people are interested in collecting long after most people forgot the toy existed.<strong> </strong>While some collectors have ideas on how to gauge what might or might not end up being valuable later, there seems to be a considerable amount of luck involved.</p>
Stamps<p> The hobby of kings has occasionally made some people as rich as one, with rare stamps and extensive collections fetching high prices at auction.</p><p> One of the famous "Inverted Jenny," stamps, a rare misprint showing an upside-down airplane, sold for $1,593,000 at <a href="https://www.linns.com/news/us-stamps-postal-history/2018/november/nov-15-jenny-invert-sale-record.html" target="_blank" rel="noopener noreferrer">auction</a>. The most valuable stamp in the world, the British Guiana 1c magenta, last sold for $9,480,000, a billion times its face <a href="http://www.sothebys.com/en/auctions/2014/magenta-n09154.html" target="_blank" rel="noopener noreferrer">value</a>. For those interested in a shorter-term investment, the USA Forever stamp has gained a face value of 75% since its introduction and can still be used to send a letter.</p>
Coins<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNTUxNjY2Ny9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYzMjUwNzk3OX0.HMBXb1mbiL0D-JbFcD7pBWNZ8TcOB4mzcJ6ri2aCNOg/img.jpg?width=1245&coordinates=0%2C1%2C0%2C1&height=700" id="41fe2" class="rm-shortcode" data-rm-shortcode-id="57f1ae74688caf29e150c4ce2f7c5b41" data-rm-shortcode-name="rebelmouse-image" data-width="1245" data-height="700" />
SMARTER FASTER trademarks owned by Freethink Media, Inc. All rights reserved.