There is increasingly talk about moving “upstream” to improve health and reduce health care costs, e.g., working to prevent disease before it happens by addressing the social and environmental determinants of health.
Among those championing this upstream approach is Rishi Manchanda, M.D. In his TED book, The Upstream Doctors, Manchanda argues for more “upstreamists” — physicians who see their work as including a “duty not only to prescribe a clinical remedy but to tackle sickness at its source.”
As an example of upstream medicine in practice, Manchanda recounts the story of a former patient, Veronica, who suffered from severe chronic headaches. Her interaction with the health care system had resulted in inconclusive medical tests and an expensive visit to the emergency room, but no answers as to the cause of her headaches, let alone a solution.
Manchanda took a different approach.
He used a questionnaire to identify risk factors in her daily life and discovered that Veronica was exposed to mold and cockroach allergens that could be the cause of her health issues. Instead of subjecting her to more medical tests, she was referred to a tenants’ rights group and received a follow up visit from a community health worker from his practice. In three months, Veronica was feeling better and her headaches subsided.
Moving Beyond the Individual Patient
Veronica’s story illustrates how clinicians can effectively address the social determinants of health by using tools that assess a patient’s community and environmental circumstances, as well as by including non-medical providers as part of a health care team. This approach is a necessary evolution in the practice of medicine that will improve patient care.
But that’s not the whole story.
Even if clinicians address the social factors that contribute to a patient’s poor health, they are still working at the individual level, treating disease person by person. “Upstream” clinicians can be more effective if they partner with the existing, very capable governmental public health system.
Extending the health care team to include nurse practitioners, physician assistants, and other non-clinical staff including benefits counselors, behavioral and mental health counselors, community health workers, and pharmacy technicians brings value to the individual patient. A partnership with the public health department, on the other hand, allows us to improve health for the whole community.
If the local public health department had been involved in Manchanda’s practice, many more than just Veronica could have benefited.
Coordinated Surveillance and Investigation
Veronica’s story represents one snapshot of life within a large, thriving, complex community. This individual information has tremendous potential to tell us about the community and its health if it can be aggregated across individual medical practices and health care systems.
Sharing these data with public health officials allows for analysis at the community level and can identify places where several individuals have the same problem. When disease clusters are identified, public health departments have experts trained in disease investigation that can pinpoint social and environmental risk factors and then develop strategies tailored to reduce the incidence and complexity of disease.
If health care providers in a community had been sharing information about patients with the local health department, public health officials might have found that Veronica was not alone and many others were experiencing similar health concerns. The public health department could then gather information about where these people were living, potential environmental triggers, the frequency of tenant complaints filed with the local housing authority, and other variables that could help us understand the cause of this common health issue.
Community-Level Strategies and Actions
When a health issue is caused by a shared social or environmental factor, the local health department can act at a community level. For example, local health departments can engage local media to raise awareness of the problem or develop public education campaigns. If you have ever seen a public service announcement about wearing a seat belt, washing your hands to prevent flu, or vaccinating against disease, you probably have your public health department to thank.
These public health messages can have an even greater impact when they are tailored to specific neighborhoods and coordinated with health care providers. As a government agency, the local health department has regulatory and statutory options, which it can leverage to change health policies and promote regulations that directly address the root causes of disease.
In Veronica’s case, involving the local health department may have led to every rental property owner in the city receiving a letter reiterating their responsibilities as landlords. The local health department could have engaged the local housing authority to improve the oversight, monitoring, and enforcement of existing regulations or determine if new regulations were needed to improve housing conditions. In extreme cases, the local public health department could condemn buildings or revoke a property owner’s ability to rent a property.
Effectively Tackling Upstream Health Issues Requires Public Health Departments
Medicine alone cannot fix problems that are rooted in social and environmental determinants of health.
The Upstream Doctors presents a vision for clinical medicine that recognizes that treating disease is not enough. Manchanda’s perspective on upstream health issues is a step forward in transforming how we see and respond to issues of health and disease in our communities, but the local health department should be included as a partner that is skilled in addressing the social determinants of disease and capable of community-level action.
Today’s health care problems are rooted in individual health choices shaped by the many contexts in which people live. Medicine and public health simply cannot afford to continue to work in their separate silos. Public health and primary care professionals must start to see their work as components of an integrated health system if we are to improve health across the board, from clinic to community.
In The Upstream Doctors, Manchanda retells an oft-cited parable of three friends who see children drowning in a river. Two rush into the water to save the children. The third friend swims upstream, acting to “stop whoever or whatever is throwing these children in the water.”
Here’s a different spin to this story. What if that third friend recalled meeting the people who lived upstream and called them? With that phone call, they quickly take action to find and stop the problem at its source.
Both upstreaming solutions work, but isn’t it more effective to communicate with each other and align our resources rather than starting a series of long, upstream swims?