'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.
Research suggests that aging affects a brain circuit critical for learning and decision-making.
As people age, they often lose their motivation to learn new things or engage in everyday activities. In a study of mice, MIT neuroscientists have now identified a brain circuit that is critical for maintaining this kind of motivation.
Researchers develop the first objective tool for assessing the onset of cognitive decline through the measurement of white spots in the brain.
- MRI brain scans may show white spots that scientists believe are linked to cognitive decline.
- Experts have had no objective means of counting and measuring these lesions.
- A new tool has just been published that both counts white spots and cleverly measures their volumes.
White spots and educated guesses<p>The white spots, or "hyperintensities," are brain lesions, fluid-filled holes in the brain believed to have been left behind by the breaking down of blood vessels that had previously provided nourishment to brain cells.</p><p>Prior to the new research, the quantity of white spots was assessed using an imprecise three-point scale indicating an ascending likelihoods of dementia: A minimal number of spots was considered as level 1, a medium number of spots level 2, and a great number of them level 3.</p>
How the new measurements were derived<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNDYwMTc1OS9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYzNDQ1ODExNX0.vqhQJSvL99KjOe24TOs4E8R7c6-pprbXYSrGcIqbVps/img.jpg?width=980" id="c64d9" class="rm-shortcode" data-rm-shortcode-id="002d9b8ef47b5a86c3a387ad2cd90629" data-rm-shortcode-name="rebelmouse-image" />
Credit: sfam_photo/Shutterstock<p>The team of researchers from NYU's Langone's <a href="https://med.nyu.edu/departments-institutes/neurology/divisions-centers/center-cognitive-neurology" target="_blank">Center for Cognitive Neurology</a> and <a href="https://med.nyu.edu/departments-institutes/neurology/divisions-centers/center-cognitive-neurology/alzheimers-disease-research-center" target="_blank">Alzheimer's Disease Research Center</a> were led by <a href="https://med.nyu.edu/faculty/jingyun-chen" target="_blank">Jingyun "Josh" Chen</a>. They analyzed 72 MRI scans from a national database of older people taken as part of the <a href="http://adni.loni.usc.edu" target="_blank">Alzheimer's Disease Neuroimaging Initiative</a> (ADNI). The scans were mostly of white people over age 70, and there were a roughly equivalent number of men and women. Some had normal brain function, some were presenting moderate cognitive decline, and some had severe dementia.</p><p>Without knowing each individual's diagnosis, the researchers analyzed the white spots in their scans. While the team counted each scan's lesions, the innovation they introduced was the production of a 3D measurement for each lesion's fluid volume. The measurement was derived by measuring a lesion's distance from opposite sides of the brain.</p><p>Measurements of 0 milliliters (mL) were assessed for areas without white spots, with other white spots coming up as containing 60 mL of fluid. Chen's team predicted that volumes over 100 milliliters could signify severe dementia.</p><p>"Amounts of white matter lesions above the normal range should serve as an early warning sign for patients and physicians," Chen tells <a href="https://nyulangone.org/news/white-matter-lesion-mapping-tool-identifies-early-signs-dementia" target="_blank">NYU Langone Health NewsHub</a>.</p><p>When the team compared the likely diagnoses derived from their calculations against the individuals' medical records, they found that their predictions were correct about 7 out of 10 times.</p><p>The researchers compiled their formulas into a tool that's available to physicians online for free online at <a href="https://github.com/jingyunc/wmhs" target="_blank" rel="noopener noreferrer">GitHub</a>. The researchers plan to further refine and test it using an additional 1,495 brain scans representing a more diverse group of individuals from the ADNI database.</p>
The new tool and its limits<p>Chen notes that white spots alone may not tell the entire story of an individual's cognitive decline or the onset of dementia. Other factors must be considered as well, including memory loss, hypertension, and brain injuries.</p><p>Nonetheless, says senior investigator <a href="https://med.nyu.edu/faculty/yulin-ge" target="_blank">Yulin Ge</a>, "Our new calculator for properly sizing white matter hyperintensities, which we call 'bilateral distancing,' offers radiologists and other clinicians an additional standardized test for assessing these lesions in the brain, well before severe dementia or stroke damage."</p><p>Having an objective means of measuring white hyperintensities will allow physicians not only to get a better handle on the association between white spots and dementia, but also to track the spots alongside changes to a person's tau and beta-amyloid proteins, two chemicals implicated in Alzheimer's disease and dementia.</p>
Why not just divide the United States in slices of equal population?
- Slicing up the country in 10 strips of equal population produces two bizarre maps.
- Seattle is the biggest city in the emptiest longitudinal band, San Antonio rules the largest north-south slice.
- Curiously, six cities are the 'capitals' of both their horizontal and vertical deciles.
Sweeping re-alignments<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNDYwMTAwOC9vcmlnaW4ucG5nIiwiZXhwaXJlc19hdCI6MTYyMzU3ODA1NH0.u_5xakBvkYwgPtiwLU3z-1e082hBeqwS4Rl1uiJqdF4/img.png?width=980" id="23ff1" class="rm-shortcode" data-rm-shortcode-id="24a5b6ec251a11f3ed7aaefc205dde17" data-rm-shortcode-name="rebelmouse-image" alt="Printed in March 1812, this political cartoon was drawn in reaction to the newly drawn state senate election district of South Essex created by the Massachusetts legislature to favor the Democratic-Republican Party candidates of Governor Elbridge Gerry over the Federalists. The caricature satirizes the bizarre shape of a district in Essex County, Massachusetts, as a dragon-like "monster". Federalist newspaper editors and others at the time likened the district shape to a salamander, and the word gerrymander was a portmanteau of that word and Governor Gerry's last name." />
The original cartoon of the 'Gerry-Mander', published in 1812 in the Boston Centinel.
Image: Elkanah Tisdale (1771-1835), Public Domain.<p>One way for a political party to manipulate the outcome of elections is to 'gerrymander' electoral districts: manipulate their boundaries to increase the likelihood of a favorable outcome (see also #<a href="https://bigthink.com/strange-maps/53-ever-been-ger..." target="_blank">53</a>).</p><p><span></span>The term is almost as old as the United States itself, and the practice continues to disfigure the electoral map to this day. Perhaps these maps can serve as the inspiration for a radical solution. </p><p><span></span>They show the contiguous United States (i.e. without Alaska and Hawaii) sliced latitudinally and longitudinally into ten straight-bordered bands of varying size, so that each contains exactly 10 percent of the population. </p><p><span></span>Although certainly not intended as a reflection on electoral redistricting, it's tempting to see these sweeping re-alignments of the U.S. as a suggestion with some potential in that direction. </p>
United Strips of America<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNDYwMTA4MS9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTY0NzE1MjQ1MX0.WpISo-g15B5O3qXbHXHf-7lQtAainpO7zPuizXWFOGs/img.jpg?width=980" id="d6656" class="rm-shortcode" data-rm-shortcode-id="72ed7c905283f9979ec0f82d451ad261" data-rm-shortcode-name="rebelmouse-image" alt="Reddit user curiouskip used U.S. Census population data to divide the 'Lower 48' into deciles (ten equal parts), each representing about 30.8 million people. Each decile is consigned its most populous city as 'capital'." />
The contiguous United States, divided into horizontal and vertical deciles.
Image: u/curiouskip, reproduced with kind permission.<p>Reddit user curiouskip used U.S. Census population data to divide the 'Lower 48' into deciles (ten equal parts), each representing about 30.8 million people. Each decile is consigned its most populous city as 'capital'.</p><p><span></span>Looking at the top map, which divides the U.S. into 10 longitudinal strips, we see</p><ul><li>Seattle rules the northernmost slice of territory. It is the broadest, and therefore also the emptiest one.</li><li>The Chicago, Omaha, New York City and Indianapolis strips complete the northern half of the country. And indeed: 50 percent of the population occupies roughly one half of the country, from north to south.</li><li>The dividing line between the top and bottom halves of the country runs from just north of the San Francisco Bay to halfway across the Delmarva Peninsula.</li><li>Capital cities of the southern strips are San Jose, Charlotte, Los Angeles, San Diego, and Houston.</li><li>The Houston Strip is divided into two non-contiguous areas. Florida maintains its panhandle, albeit much reduced. </li></ul><p>The bottom map shows the U.S. divided latitudinally into 10 bands of equal population. </p><ul><li>San Jose and Los Angeles both retain their capital status, this time of the two westernmost strips.</li><li>San Antonio is the main city of the Big Empty, more than twice as wide as the second-broadest band.</li><li>The dividing line between America's eastern and western half, population-wise, is far off-center: it skirts the eastern edge of Chicago, making the western half much bigger than the eastern one.</li><li>Houston, Chicago, and Indianapolis also remain the largest cities in their respective bands.</li><li>Further east, Jacksonville and Philadelphia get to rule over their strip of America, while Charlotte and New York City keep winning, both vertically and horizontally.</li></ul><p>Redistricting a country into zones of equal population – and that being your only criterium – will create districts that are randomly diverse, and perhaps also, at least in this case, unmanageably large. </p><p>However, mixing up the political map with a bunch of straight lines as the only instrument is something that has been considered before. Usually, the objective is the wholesale removal of age-old divisions. <br></p>
Perfectly square departments<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNDYwMTEzOS9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYwOTQyMzIwOH0.kYuf58g0bjsPL9DGPq5PycZ7PDJMnItT0rfrPonOP3k/img.jpg?width=980" id="89a68" class="rm-shortcode" data-rm-shortcode-id="5b81a43e785997bb1f11f72548659a9f" data-rm-shortcode-name="rebelmouse-image" alt="\u200bCh\u00e2ssis figuratif du territoire de la France partag\u00e9 en divisions \u00e9gales entre elles, proposition annex\u00e9e au rapport du 29 septembre 1789 \u00e0 l'Assembl\u00e9e nationale de la commission dite Siey\u00e8s-Thouret" />
France divided into 80-odd geometrical departments: failed proposal by Jacques-Guillaume Thouret (1790).
Image: Centre historique des Archives nationales – Atelier de photographie; public domain.
European Pie<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNDYwMTQ0Ny9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYxNTE5NDE3OX0.dPcY1tkO7nwkx6IX98Sleh7AmBpDnwlcJLfC_Z-WBlY/img.jpg?width=980" id="b35d7" class="rm-shortcode" data-rm-shortcode-id="84509a9425e13c0dd8fbe00df28a197e" data-rm-shortcode-name="rebelmouse-image" />
In this rather outlandish proposal, continental Europe's 24 cantons center on Vienna.
Image: PJ Mode Collection of Persuasive Maps, Cornell University.<p>And in 1920, an anonymous author – possibly the Austrian P.A. Maas – proposed slicing up Post-World-War-I Europe as a pie, into 24 slices that would center on Vienna's St. Stephen's Cathedral. Each of those slices would be made up of a wide and random variety of linguistic, ethnic, and religious groups – and that would be the point: the better to unite them all into one massive superstate (see also #<a href="https://bigthink.com/strange-maps/a-bizarre-peace-proposal-slice-europe-up-like-a-pie" target="_blank">851</a>).</p><p>Needless to say, both plans never left the drawing board. Would a proposal for the longitudinal and/or latitudinal redistricting of the U.S. have more traction? <br></p>
Coast-to-coast precedents<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNDYwMTIwOS9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTY1MDM2OTE0OX0.52UjcA_YD9Y9UB9_hoSctI_xBrRDALZ2DRLkIo9a8RM/img.jpg?width=980" id="10784" class="rm-shortcode" data-rm-shortcode-id="1999808ea21e11162fdb9181c3912753" data-rm-shortcode-name="rebelmouse-image" alt="Illustration of the Connecticut Charter boundary, 1662" />
Putting the 'connect' into Connecticut: the Nutmeg State extending from the Pacific to the Atlantic.
Image: Connecticuthistory.org<p>Well, for one, coast-to-coast polities have some pedigree in America's past: some of the first colonies had claims that extended from the Atlantic all the way to the Pacific. </p><p>If history had gone entirely the way Connecticut would have wanted, the state would include such inland cities as Detroit, Chicago, and Salt Lake City, and extended to what is now the northern part of California.</p><p>Is such geopolitical weirdness reasonable or feasible today? Absolutely not. But in its randomness, would it be it as unfair as gerrymandering? </p><p><em><br></em></p><p><em>Decile maps of the contiguous United States reproduced with kind permission by u/curiouskip; found <a href="https://www.reddit.com/r/dataisbeautiful/comments/ijyn7p/oc_us_population_deciles_by_latitude_and_longitude/" target="_blank">here</a> on <a href="https://www.reddit.com/" target="_blank">Reddit</a>.<br></em></p><p><strong>Strange Maps #1054</strong></p><p><em>Got a strange map? Let me know at </em><a href="mailto:firstname.lastname@example.org">email@example.com</a><em>.</em></p>
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