'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.
A study finds 1.8 billion trees and shrubs in the Sahara desert
- AI analysis of satellite images sees trees and shrubs where human eyes can't.
- At the western edge of the Sahara is more significant vegetation than previously suspected.
- Machine learning trained to recognize trees completed the detailed study in hours.
Why this matters<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNDU2MDQ1OC9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYzOTkyODg5NX0.O3S2DRTyAxh-JZqxGKj9KkC6ndZAloEh4hKhpcyeFDQ/img.jpg?width=980" id="3770d" class="rm-shortcode" data-rm-shortcode-id="3c27b79d4c0600fb6ebb82e650cabec0" data-rm-shortcode-name="rebelmouse-image" />
Area in which trees were located
Credit: University of Copenhagen<p>As important as trees are in fighting climate change, scientists need to know what trees there are, and where, and the study's finding represents a significant addition to the global tree inventory.</p><p>The vegetation Brandt and his colleagues have identified is in the Western Sahara, a region of about 1.3 million square kilometers that includes the desert, <a href="https://en.wikipedia.org/wiki/Sahel" target="_blank">the Sahel</a>, and the <a href="https://www.sciencedirect.com/topics/agricultural-and-biological-sciences/subhumid-zones" target="_blank" rel="noopener noreferrer">sub-humid zones</a> of West Africa.</p><p>These trees and shrubs have been left out of previous tabulations of carbon-processing worldwide forests. Says Brandt, "Trees outside of forested areas are usually not included in climate models, and we know very little about their carbon stocks. They are basically a white spot on maps and an unknown component in the global carbon cycle."</p><p>In addition to being valuable climate-change information, the research can help facilitate strategic development of the region in which the vegetation grows due to a greater understanding of local ecosystems.</p>
Trained for trees<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNDU2MDQ3MC9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYzNTk5NTI3NH0.fR-n1I2DHBIRPLvXv4g0PVM8ciZwSLWorBUUw2wc-Vk/img.jpg?width=980" id="e02c0" class="rm-shortcode" data-rm-shortcode-id="79955b13661dca8b6e19007935129af1" data-rm-shortcode-name="rebelmouse-image" />
Credit: Martin Brandt/University of Copenhagen<p>There's been an assumption that there's hardly enough vegetation outside of forested areas to be worth counting in areas such as this one. As a result the study represents the first time a significant number of trees — likely in the hundreds of millions when shrubs are subtracted from the overall figure — have been catalogued in the drylands region.</p><p>Members of the university's Department of Computer Science trained a machine-learning module to recognize trees by feeding it thousands of pictures of them. This training left the AI be capable of spotting trees in the tiny details of satellite images supplied by NASA. The task took the AI just hours — it would take a human years to perform an equivalent analysis.</p><p>The department's Christian Igel, a co-author, says "This technology has enormous potential when it comes to documenting changes on a global scale and ultimately, in contributing towards global climate goals. It is a motivation for us to develop this type of beneficial artificial intelligence."</p><p>"Indeed," says Brandt says, "I think it marks the beginning of a new scientific era."</p>
Looking ahead and beyond<p>The researchers hope to further refine their AI to provide a more detailed accounting of the trees it identifies in satellite photos.</p><p>The study's senior author, Rasmus Fensholt, says, "we are also interested in using satellites to determine tree species, as tree types are significant in relation to their value to local populations who use wood resources as part of their livelihoods. Trees and their fruit are consumed by both livestock and humans, and when preserved in the fields, trees have a positive effect on crop yields because they improve the balance of water and nutrients."</p><p>Ahead is an expansion of the team's tree hunt to a larger area of Africa, with the long-term goal being the creation of a more comprehensive and accurate global database of trees that grow beyond the boundaries of forests.</p>
Younger Americans support expanding the Supreme Court and serious political reforms, says new poll.
- Americans under 40 largely favor major political reforms, finds a new survey.
- The poll revealed that most would want to expand the Supreme Court, impose terms limits, and make it easier to vote.
- Millennials are more liberal and reform-centered than Generation Z.
A 2020 study published in the journal of Psychological Science explores the idea that fake news can actually help you remember real facts better.
- In 2019, researchers at Stanford Engineering analyzed the spread of fake news as if it were a strain of Ebola. The researchers adapted a model for understanding diseases that can infect a person more than once to better understand how fake news spreads and gains traction.
- A 2020 study published in the journal of Psychological Science explores the idea that fake news can actually help you remember real facts better.
- Researchers on the project explained: "These findings demonstrate one situation in which misinformation reminders can diminish the negative effects of fake-news exposure in the short term."
Previous studies on misinformation have already paved the way to a better understanding<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNDU1NzQ4NC9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYxNjE2Mjg1Nn0.hs_xHktN1KXUDVoWpHIVBI2sMJy6aRK6tvBVFkqmYjk/img.jpg?width=1245&coordinates=0%2C800%2C0%2C823&height=700" id="fc135" class="rm-shortcode" data-rm-shortcode-id="246bb1920c0f40ccb15e123914de1ab1" data-rm-shortcode-name="rebelmouse-image" alt="fake news concept of misinformation and fake news in the media" />
How does misinformation spread?
Image by Visual Generation on Shutterstock<p><strong>What is the "continued-influence" effect?</strong></p><p>A challenge in using corrections effectively is that repeating the misinformation can have negative consequences. Research on this effect (referred to as continued-influence") has shown that information presented as factual that is later deemed false can still contaminate memory and reasoning. The persistence of the continued-influence effect has led researchers to generally recommend avoiding repeating misinformation. </p><p>"Repetition increases familiarity and believability of misinformation," <a href="https://engineering.stanford.edu/magazine/article/how-fake-news-spreads-real-virus" target="_blank" rel="noopener noreferrer">the study explains</a>.</p><p><strong>What is the "familiarity-backfire" effect?</strong></p><p>Studies of this effect have shown that increasing misinformation familiarity through extra exposure to it leads to misattributions of fluency when the context of said information cannot be recalled. <a href="https://journals.sagepub.com/doi/10.1177/0956797620952797#" target="_blank" rel="noopener noreferrer">A 2017 study</a> examined this effect in myth correction. Subject rated beliefs in facts and myths of unclear veracity. Then, the facts were affirmed and myths corrected. Subjects made belief ratings again after this. The results suggested a role for familiarity but the myth beliefs remained below pre-manipulation levels. </p>
New research into fake news has uncovered something interesting about misinformation<span style="display:block;position:relative;padding-top:56.25%;" class="rm-shortcode" data-rm-shortcode-id="ddeac998508e09fb9d1b4691d6c20d28"><iframe type="lazy-iframe" data-runner-src="https://www.youtube.com/embed/bJ5qUx1WOsg?rel=0" width="100%" height="auto" frameborder="0" scrolling="no" style="position:absolute;top:0;left:0;width:100%;height:100%;"></iframe></span><p>A 2020 study published in the journal of <a href="https://journals.sagepub.com/doi/10.1177/0956797620952797" target="_blank">Psychological Science</a> explores the idea that fake news can actually help you remember real facts better.</p><p>Fake news exposure can cause misinformation to be mistakenly remembered and believed. In two experiments, the team (led by Christopher N. Wahlheim) examined whether reminders of misinformation could do the opposite: improve memory for and beliefs in corrections to that fake news. </p><p>The study had subjects reading factual statements and then separate misinformation statements taken from news websites. Then, the subjects read statements that corrected the misinformation. Some misinformation reminders appeared before some corrections but not all. Then, subjects were asked to recall facts, indicate their belief in those recalls, and indicate whether they remembered the corrections and misinformation. </p><p>The results of the study showed that reminders increased recall and belief accuracy. These benefits were greater both when misinformation was recalled and when the subjects remembered that corrections had occurred. </p><p>Researchers on the project <a href="https://journals.sagepub.com/doi/10.1177/0956797620952797" target="_blank" rel="noopener noreferrer">explained</a>: "These findings demonstrate one situation in which misinformation reminders can diminish the negative effects of fake-news exposure in the short term.".</p><p><strong>The conclusion: fake-news misinformation that was corrected by fact-checked information can improve both memory and belief accuracy in real information.</strong></p><p>"We examined the effects of providing misinformation reminders before fake-news corrections on memory and belief accuracy. Our study included everyday fake-news misinformation that was corrected by fact-check-verified statements. Building on research using fictional, yet naturalistic, event narratives to show that reminders can counteract misinformation reliance in memory reports," <a href="https://journals.sagepub.com/doi/10.1177/0956797620952797" target="_blank" rel="noopener noreferrer">the researchers</a> explained.</p><p>"It suggests that there may be benefits to learning how someone was being misleading. This knowledge may inform strategies that people use to counteract high exposure to misinformation spread for political gain," <a href="https://www.eurekalert.org/pub_releases/2020-10/afps-rtf101620.php" target="_blank">Wahlheim said</a>.</p>
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