'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.
How Nobel Prize winner physicist Lev Landau ranked the best physics minds of his generation.
Rank 0.5 – Albert Einstein<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNDQ0NDY3NS9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYzNjI2NTU4OH0.FtBYC7oJz-ZOiiGC9y0Z50_JvQChmp-ONa3jhR3SuLA/img.jpg?width=980" id="d6f66" class="rm-shortcode" data-rm-shortcode-id="61288810a4f035ec2af8957fad4e9015" data-rm-shortcode-name="rebelmouse-image" />
Albert Einstein With Displaced Children From Concentration Camps. 1949.
Photo by Keystone-France/Gamma-Keystone via Getty Images
Rank 1<p>The group in this class of the smartest physicists included the top minds that developed the theories of quantum mechanics.</p><p><a href="http://en.wikipedia.org/wiki/Werner_Heisenberg" target="_blank">Werner Heisenberg</a> (1901 - 1976) - a German theoretical physicist, who's achieved pop-culture fame by being the name of Walter White's alter ego in <em>Breaking Bad</em>. He is known for the Heiseinberg Uncertainty Principle and his 1932 Nobel Prize award flatly states it was for nothing less than "the creation of quantum mechanics".</p><p><a href="http://en.wikipedia.org/wiki/Erwin_Schr%C3%B6dinger" target="_blank">Erwin Schrödinger</a> (1887 - 1961) - an Austrian-Irish physicist who gave us the infamous "Schroedinger's Cat" thought experiment and other mind-benders from quantum mechanics. The Nobel-prize-winner's <a href="https://en.wikipedia.org/wiki/Schr%C3%B6dinger_equation" target="_blank" rel="noopener noreferrer">Schrödinger equation</a> calculates the <a href="https://en.wikipedia.org/wiki/Wave_function" target="_blank">wave function</a> of a system and how it changes over time. </p>
Erwin Schrödinger. 1933.
Satyendra Nath Bose. 1930s.
Enrico Fermi. 1950s.
Rank 2.5<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNDQ0NDcwNy9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTY0NDE1MDIxM30.Eg6tca61EredHxjqNH29HY3UeJbgBVa1nA13EhXTooU/img.jpg?width=980" id="90f86" class="rm-shortcode" data-rm-shortcode-id="0f1e6c5e13263a77b2061e1191fd8baf" data-rm-shortcode-name="rebelmouse-image" />
Lev Landau. 1962.<p><strong>Rank 2.5</strong> is where Landau initially ranked himself, rather modestly, thinking he didn't produce any foundational accomplishments. He later moved his prominence, as his achievement mounted, to the higher <strong>1.5.</strong></p>
- Anxiety levels are increasing due to the pandemic and political uncertainty right now.
- Anxiety and depression cost the economy $50 billion in health care costs and lost work every year.
- These six books covers anxiety's physiology, environmental factors, and potential treatments.
You’re Wired for Anxiety. And You’re Wired to Handle It | Anne Marie Albano | Big Think<span style="display:block;position:relative;padding-top:56.25%;" class="rm-shortcode" data-rm-shortcode-id="006926deaed2698d42ef27cba83f173a"><iframe type="lazy-iframe" data-runner-src="https://www.youtube.com/embed/mUv37ttgQVE?rel=0" width="100%" height="auto" frameborder="0" scrolling="no" style="position:absolute;top:0;left:0;width:100%;height:100%;"></iframe></span><h2>Anxious: Using the Brain to Understand and Treat Fear and Anxiety - Joseph Ledoux</h2><p>Neuroscientist Joseph Ledoux has written <em>the</em> go-to book for understanding everything about anxiety: how it arises in consciousness, its physiological manifestation, reshaping psychotherapy, environmental stressors—you name it. Ledoux argues that you must treat the outward symptoms <em>and</em> inner causes if you want to holistically address anxiety. He points out that uncertainty about the future (and how to prepare for it) is a common trigger for anxiety disorders, which puts 2020 into perspective. </p><p style="margin-left: 20px;">"Patients with panic disorder…have a hypersensitive suffocation alarm system, which falsely detects a dangerous level of CO2 and lead to hyperventilation, which in turn produces an actual rise in CO2 (due to short, fast inspiration). The resulting dizziness and light-headedness lead the person to misinterpret the physiological changes and worry and dread follow in the panic-stick person."</p><h2>The Upside of Stress: Why Stress is Good For You, and How to Get Good At It - Kelly McGonigal</h2><p>Health psychologist Kelly McGonigal flips the anxiety script on its head in this inspiring and motivational work on the advantages of stress. Anxiety is part of life—we've known that since Freud, and intuitively, long before (Kierkegaard had a few things to say as well). What if you can reframe that physiological energy and use it as a catalyst for action? McGonigal offers plenty of ways you can do just that. </p><p style="margin-left: 20px;">"One of the effects of the biological stress response is to make you more open to your experience. You feel things more, and your ability to notice expands. You are more sensitive to other people and to your environment."</p><h2>My Age of Anxiety: Fear, Hope, Dread, and the Search for Peace of Mind - Scott Stossel</h2><p>Scott Stossel, a longtime editor of <em>The Atlantic</em>, has suffered from crippling anxiety for years. This half-memoir, half-exposé offers a compassionate gaze into the personal and societal complications of anxiety. Stossel investigates the many attempts at therapy, from the common to the outlandish. Most importantly, he offers real-world advice for controlling and managing symptoms. </p><p style="margin-left: 20px;"> "Conscientious people who were highly neurotic tended to be more reflective, more goal oriented, more organized, and better at planning than average; they tended to be effective, 'high-functioning' workers—and to be better at taking care of their physical health than other workers."</p>
Photo: Lightspring / Shutterstock<h2>The Trauma of Everyday Life - Mark Epstein</h2><p>In this beautiful handbook for life, psychiatrist Mark Epstein puts Buddhism into action. He claims humans are all traumatized in some capacity, which creates lasting and often subconscious anxiety. Epstein uses the vast toolkit of Buddhist philosophy to reengineer trauma as a catalyst for transformation. The first step is not only striving for what is good and pleasant. You have to face trauma head-on. If you do, Epstein assures us, the world is yours. </p><p style="margin-left: 20px;">"The key, taught the Buddha, lies in not taking trauma personally. When it is seen as a natural reflection of the chaotic universe of which we are a part, it loses its edge and can become a deeper object of mindfulness."</p><h2>How Emotions Are Made: The Secret Life of the Brain - Lisa Feldman Barrett</h2><p>We don't react to situations, writes psychology professor Lisa Feldman Barrett. Rather, we constantly create our reality. It only feels like reacting because of how deeply our patterns are imprinted. Fortunately, patterns are malleable. In this spellbinding book about the nature of emotions and human consciousness, Barrett leads the reader through the historical construction of emotions, assuring you that you don't need to be the victim of your mind. You are the author of your experiences. </p><p style="margin-left: 20px;">"[Emotions] are not triggered; you create them. They emerge as a combination of the physical properties of your body, a flexible brain that wires itself to whatever environment it develops in, and your culture and upbringing, which provide that environment." </p><h2>Wayfinding: The Science and Mystery of How Humans Navigate the World - M.R. O'Connor</h2><p>There's something beautiful about getting lost. Not only does it make you notice your surroundings, it activates parts of your brain that remain silent when you default to using Waze for navigation. Science writer Maura O'Connor's exquisite book reminds us of what we've lost in an automated world and the anxiety this "ease" adds to our lives. Of course, she also offers solutions that keep you mentally engaged and emotionally healthy. </p><p style="margin-left: 20px;">"Mapping is an act of committing to memory the experience of bodily movement and reenacting it. It's a kind of performance, like telling a story."</p><p>--</p><p><em>Stay in touch with Derek on <a href="http://www.twitter.com/derekberes" target="_blank">Twitter</a>, <a href="https://www.facebook.com/DerekBeresdotcom" target="_blank" rel="noopener noreferrer">Facebook</a> and <a href="https://derekberes.substack.com/" target="_blank" rel="noopener noreferrer">Substack</a>. His next book is</em> "<em>Hero's Dose: The Case For Psychedelics in Ritual and Therapy."</em></p>
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