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.
What is upstreamism?<p>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.</p><p>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.</p><p>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.</p><p>Rishi Manchanda, founder of <a href="https://www.healthbegins.org/" target="_blank">HealthBegins</a> 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.</p><p>In <a href="https://www.ted.com/talks/rishi_manchanda_what_makes_us_get_sick_look_upstream/transcript?language=en" target="_blank">his TED talk</a>, 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. </p><p>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.</p>
Swimming against the social current?<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8xOTM3MjQxNC9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYyMDIxMjU3OH0.hXiAIgpOk0vOWDNVol2RTS8cMylTxphJ2PyY-hX03OM/img.jpg?width=1245&coordinates=0%2C629%2C0%2C2&height=700" id="92e2e" class="rm-shortcode" data-rm-shortcode-id="ebe1f0c66196f4aca1a0980bdeec9eb0" data-rm-shortcode-name="rebelmouse-image" />
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)<p>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.</p><p>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 <a href="https://www.washingtonpost.com/news/energy-environment/wp/2016/01/27/its-not-just-flint-poor-communities-across-the-country-live-with-extreme-polluters/?utm_term=.7dbde0676d39" target="_blank">pollutant-free water</a>, <a href="http://frac.org/obesity-health/low-income-food-insecure-people-vulnerable-poor-nutrition-obesity" target="_blank">full-service grocery stores and farmers markets</a>, and parks and playgrounds. The stress of such environments leads to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2186297/" target="_blank">higher rates of depression</a>, <a href="https://inequality.stanford.edu/sites/default/files/PathwaysWinter11_Evans.pdf" target="_blank">unresponsive parenting practices</a>, and even increased rates of mortality.</p><p>"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."</p><p>That's a lot for health care professionals to be responsible for, especially when one factors in the exorbitant rates of burnout facing <a href="https://www.medicaldaily.com/many-american-doctors-overworked-likely-make-medical-errors-due-burnout-425644" target="_blank">doctors</a> and <a href="https://thehospitalleader.org/americas-physicians-overworked-and-burning-out/" target="_blank">physicians</a>. </p>