'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.
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They came from different places and with different ideas, which still resonate today
- Early British settlement of the American colonies came in four distinct waves, from different places.
- Puritans, Cavaliers, Quakers and Borderers had their own ideas of what America should be.
- Some of the cultural fault lines in today's America can be traced back to those differences.
Four 'folkways'<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNDQ0MDY2NC9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYzOTAzNzk0OX0.YfBxVdS46dX1eUZhGA_4remlW4YYMIxlZ65wjQ2pyMs/img.jpg?width=980" id="d2108" class="rm-shortcode" data-rm-shortcode-id="2efd697c8c1a31a446da2d4f34168094" data-rm-shortcode-name="rebelmouse-image" alt="\u200bQuaker pioneer William Penn (center) treating with the Delaware Indians for the purchase of what was to become Pennsylvania." />
Quaker pioneer William Penn (center) treating with the Delaware Indians for the purchase of what was to become Pennsylvania.
Image: frieze by Constantino Brumidi (1865) in the Rotunda of the US Capitol; via Architect of the Capitol - public domain.<p>How many Americans are of British descent? It's a surprisingly difficult question to answer. Is that because, in an age of hyphenated identities, the founding one still is the default? Or has that identity become so amalgamated that it is now irrelevant? Perhaps the correct answer is: a bit of both. </p><p><span></span>In the 1980 Census, 61.3 million Americans (32%) self-reported British ancestry; most claimed English descent (26%), followed by Scottish (4%), and tiny amounts of Welsh (<1%) and Northern Irish. In the 2010 Census, that figure had dropped to 37.6 million (14%), with just 8% reporting English heritage, 3% Scottish and 2% Scotch-Irish. </p><p>The precipitous drop in self-reported British antecedents corresponds in part with the rise of those who identify as (unhyphenated) 'American', up from 12.4 million (5%) in the 1990 Census to 20.2 million in 2000 (7%) – the largest growth of any ethnic group in the 1990s.</p><p>However, back around the year 1700, about 80% of the population of what was to become the United States were of English (or Welsh) descent, with about 11% of African origin, and the rest being Dutch (4%), Scottish (3%) and other European. The imprint of the British on early American society was overwhelming, diverse and long-lasting: the regional and cultural differences between the settler groups created distinct regional and cultural identities in America.</p><p>That's the argument made by David Fischer, a history professor who in 1989 published a 900-page treatise on early migration to North America called <em><a href="https://global.oup.com/ushe/product/albions-seed-9780195069051" target="_blank">Albion's Seed</a></em>. He identified four British 'folkways' that came over to the other side of the Atlantic in the 17th and 18th centuries (<em>see map</em>), each with their own ideas about the liberty they wanted to find there.<br></p>
From exodus to flight<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNDQ0MDY2NS9vcmlnaW4ucG5nIiwiZXhwaXJlc19hdCI6MTY0NDg1MzczOX0.-LwTLCpuIub9QhTVWL9vhnd8Jlz9j8aRyt9bePqQPuo/img.png?width=980" id="65f97" class="rm-shortcode" data-rm-shortcode-id="4457df0ca7f66fe87026322bad771da6" data-rm-shortcode-name="rebelmouse-image" alt="\u200bMap showing the origin and destination of four British 'folkways' that influenced American society." />
Map showing the origin and destination of four British 'folkways' that influenced American society.
Image: Geni.com<p><strong></strong><strong>1. The Exodus (1629-41)</strong></p><ul> <li>About 21,000 Puritans, migrating from East Anglia to New England.</li><li>These religious fundamentalists believed in 'ordered liberty': everybody had the right to live by their own rules, and the duty to live according to God's law.</li><li>The Puritans were a major influence on the culture of the Northeastern US, especially in terms of business and education.</li></ul><p>These religious fundamentalists are the ones who came over on the Mayflower and gave America Thanksgiving and the self-image of being a 'City on a Hill'. Puritan society was gloomy and repressive: 'exceeding the bounds of moderation' was a punishable offense, and even just 'wasting time' got you into trouble.</p>The other side of the coin: life was very well-ordered. There was little income inequality and crime rates were low. Not only was charity towards poor the rule, being uncharitable was, yes, a punishable offense. Domestic abuse was punished severely. Women had a relatively high degree of equality. And government operated via town assemblies in which all could have a say.<br><br><strong>2. Cavaliers and their Servants (1642-75)</strong><ul><li>Some 45,000 Cavaliers drawn from English nobility and their indentured servants, migrating from the South of England to Virginia and the Lowland South.</li><li>These aristocrats believed in 'hegemonic liberty': dominion over self, and others. In other words: keeping slaves was okay, but domination by others was not.</li><li>The Cavaliers were the foundation of plantation culture in the South. </li></ul><p>The Cavaliers came from the losing side of the Civil War in England, which was now led by the Puritan-inspired Oliver Cromwell. Royalist, Anglican and aristocratic, they brought along with them their indentured servants – more than 75% of the total migration – hoping to recreate in Virginia and environs the socially stratified agrarian society they had left behind.</p><p><span></span>When their servants began dying en masse, they started importing African slaves, laying the groundwork for the race-based slavery system that underpinned the economy of the South until the end of the Civil War.</p><strong>3. The Friends' Migration (1675-1725)</strong><ul><li><strong></strong>Around 23,000 Quakers, migrating from Northern England to the Delaware Valley in Pennsylvania, and later to the Midwest.</li><li>These religious liberals believed in 'reciprocal liberty': granting others the freedoms they wanted for themselves, including the right to vote, to own, to be free, to worship and to a fair trial.</li><li>Quakers had an important impact on the industrial culture of the Mid-Atlantic and Midwestern regions of the US.</li></ul><span></span>Halfway between the fun-hating Puritans and the pleb-hating Cavaliers, the Quakers seem modern and likeable. Believing everybody intrinsically good, they practiced tolerance, pacifism, gender equality and racial harmony. They opposed slavery, the death penalty, and cruelty to animals and children.<p>Quakers replaced a wide range of social acknowledgements according to rank (bows, nods, grovels) by a single, neutral equivalent: the handshake. Quakerism was perhaps one of the first Christian denominations to become indistinguishable from liberal, secular modernity. On the other hand, they were more prudish even than the Puritans. Doctors had a hard time treating Quakers because they described everything from their necks to their waists as their 'stomachs', and everything below as their 'ankles'. </p><p><strong>4. The Flight from Northern Britain (1717-75)</strong></p><ul><li>Some 250,000 'Borderers', migrating from the Anglo-Scottish borderlands and Ulster to the Backcountry of Appalachia.</li><li>These individualists believed in 'natural liberty': freedom to do as one pleases, without interference from society or government.</li><li>Borderers contributed to the rural culture of America's South and the ranch culture of its West. </li></ul><p><span></span>Inhabiting the border regions between Scotland and England, and between protestant settlers and catholic natives in Ireland, the Borderers were used to violence and lawlessness, and to lives that were nasty, brutish and short. </p>It is no coincidence that they ended up in Appalachia, at that time itself a violent border region. It was the kind of world they knew. Borderers were wary of government, prone to violent family feuds and not bothered by traditional morality. By one estimate, in the year 1767, 94% of all 'backcountry' brides were pregnant on their wedding day.<p><span></span>These Borderers were not much beloved by other settler groups in America. One Pennsylvanian writer called them "the scum of two nations". But the Borderers also contributed vigorously to the success of both the American Revolution and America's westward expansion. </p>
'Blue' vs. 'Red'?<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNDQ0MDczNy9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTY1MzE5MTc4NH0.EtbfEc9BlGG8R4VlyHr2W7kQ0LzvRdAHRRRlsEI01Pg/img.jpg?width=980" id="ce2a3" class="rm-shortcode" data-rm-shortcode-id="ba2cd744238f9a08ce63e85be2860528" data-rm-shortcode-name="rebelmouse-image" alt="Representative Preston Brooks (SC) caning Senator Charles Sumner (MA) on the Senate floor. The attack, on 22 May 1856, symbolised the breakdown of civil discourse between North and South, prefiguring the Civil War." />
Representative Preston Brooks (SC) caning Senator Charles Sumner (MA) on the Senate floor. The attack, on 22 May 1856, symbolised the breakdown of civil discourse between North and South, prefiguring the Civil War.
Image: lithograph by John L. Magee (1856); public domain.<p>It's tempting, and perhaps not entirely unjustified, to see in these four strains of British 'folkways' the antecedents of some of America's current cultural divides. One might for example see Puritans and Quakers as constituting elements of the 'blue' tribe, while Borderers and Cavaliers could be considered the ancestors of the 'red' tribe.</p><p><span></span>But thinking of America as a "death match between Puritan-Quaker culture and Cavalier-Borderer culture", as one commentator put it, is perhaps a bit too easy. There may be plenty of overlap within either pair, there is also much to distinguish each from the other. And then there are other and subsequent migrations contributing to and complicating the picture.</p><p>Nevertheless, a bit of cultural archeology can be illuminating, if only to see where the bodies are buried.<br></p><p><strong><br></strong></p><p><strong>Strange Maps #1049</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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