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'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."

That's a lot for health care professionals to be responsible for, especially when one factors in the exorbitant rates of burnout facing doctors and physicians.

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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A massive star has mysteriously vanished, confusing astronomers

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A "very massive star" in the Kinman Dwarf galaxy caught the attention of astronomers in the early years of the 2000s: It seemed to be reaching a late-ish chapter in its life story and offered a rare chance to observe the death of a large star in a region low in metallicity. However, by the time scientists had the chance to turn the European Southern Observatory's (ESO) Very Large Telescope (VLT) in Paranal, Chile back around to it in 2019 — it's not a slow-turner, just an in-demand device — it was utterly gone without a trace. But how?

The two leading theories about what happened are that either it's still there, still erupting its way through its death throes, with less luminosity and perhaps obscured by dust, or it just up and collapsed into a black hole without going through a supernova stage. "If true, this would be the first direct detection of such a monster star ending its life in this manner," says Andrew Allan of Trinity College Dublin, Ireland, leader of the observation team whose study is published in Monthly Notices of the Royal Astronomical Society.

So, em...

Between astronomers' last look in 2011 and 2019 is a large enough interval of time for something to happen. Not that 2001 (when it was first observed) or 2019 have much meaning, since we're always watching the past out there and the Kinman Dwarf Galaxy is 75 million light years away. We often think of cosmic events as slow-moving phenomena because so often their follow-on effects are massive and unfold to us over time. But things happen just as fast big as small. The number of things that happened in the first 10 millionth of a trillionth of a trillionth of a trillionth of a second after the Big Bang, for example, is insane.

In any event, the Kinsman Dwarf Galaxy, or PHL 293B, is far way, too far for astronomers to directly observe its stars. Their presence can be inferred from spectroscopic signatures — specifically, PHL 293B between 2001 and 2011 consistently featured strong signatures of hydrogen that indicated the presence of a massive "luminous blue variable" (LBV) star about 2.5 times more brilliant than our Sun. Astronomers suspect that some very large stars may spend their final years as LBVs.

Though LBVs are known to experience radical shifts in spectra and brightness, they reliably leave specific traces that help confirm their ongoing presence. In 2019 the hydrogen signatures, and such traces, were gone. Allan says, "It would be highly unusual for such a massive star to disappear without producing a bright supernova explosion."

The Kinsman Dwarf Galaxy, or PHL 293B, is one of the most metal-poor galaxies known. Explosive, massive, Wolf-Rayet stars are seldom seen in such environments — NASA refers to such stars as those that "live fast, die hard." Red supergiants are also rare to low Z environments. The now-missing star was looked to as a rare opportunity to observe a massive star's late stages in such an environment.

Celestial sleuthing

In August 2019, the team pointed the four eight-meter telescopes of ESO's ESPRESSO array simultaneously toward the LBV's former location: nothing. They also gave the VLT's X-shooter instrument a shot a few months later: also nothing.

Still pursuing the missing star, the scientists acquired access to older data for comparison to what they already felt they knew. "The ESO Science Archive Facility enabled us to find and use data of the same object obtained in 2002 and 2009," says Andrea Mehner, an ESO staff member who worked on the study. "The comparison of the 2002 high-resolution UVES spectra with our observations obtained in 2019 with ESO's newest high-resolution spectrograph ESPRESSO was especially revealing, from both an astronomical and an instrumentation point of view."

Examination of this data suggested that the LBV may have indeed been winding up to a grand final sometime after 2011.

Team member Jose Groh, also of Trinity College, says "We may have detected one of the most massive stars of the local Universe going gently into the night. Our discovery would not have been made without using the powerful ESO 8-meter telescopes, their unique instrumentation, and the prompt access to those capabilities following the recent agreement of Ireland to join ESO."

Combining the 2019 data with contemporaneous Hubble Space Telescope (HST) imagery leaves the authors of the reports with the sense that "the LBV was in an eruptive state at least between 2001 and 2011, which then ended, and may have been followed by a collapse into a massive BH without the production of an SN. This scenario is consistent with the available HST and ground-based photometry."

Or...

A star collapsing into a black hole without a supernova would be a rare event, and that argues against the idea. The paper also notes that we may simply have missed the star's supernova during the eight-year observation gap.

LBVs are known to be highly unstable, so the star dropping to a state of less luminosity or producing a dust cover would be much more in the realm of expected behavior.

Says the paper: "A combination of a slightly reduced luminosity and a thick dusty shell could result in the star being obscured. While the lack of variability between the 2009 and 2019 near-infrared continuum from our X-shooter spectra eliminates the possibility of formation of hot dust (⪆1500 K), mid-infrared observations are necessary to rule out a slowly expanding cooler dust shell."

The authors of the report are pretty confident the star experienced a dramatic eruption after 2011. Beyond that, though:

"Based on our observations and models, we suggest that PHL 293B hosted an LBV with an eruption that ended sometime after 2011. This could have been followed by
(1) a surviving star or
(2) a collapse of the LBV to a BH [black hole] without the production of a bright SN, but possibly with a weak transient."

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