Upstreamists: Where Health Begins

The debate centers around a simple question: “In the context of growing healthcare costs, ever increasing rates of obesity, diabetes and poverty-related diseases, would it make sense for our doctors and hospitals to work with communities to fix the leaks in our apartments causing mold or the neighborhood designs resulting in food deserts?”

There are compelling arguments for why this is not the job of doctors. Their jurisdiction does not go beyond the walls of the hospital building. In fact, how could it when the job of managing complex diseases is sufficiently onerous? Such concerns would actually distract doctors from their primary task, which is providing the best care to the person directly in front of them. We first discussed the nuanced limitations of the doctor’s role with Dr. Malika Fair

HealthBegins continues this conversation in profound ways. Founder Dr. Rishi Manchanda argues that empowering doctors to address these underlying causes of illness may be the only way to change the American healthcare system, which is growing increasingly expensive.

Dr. Manchanda has spent the last decade caring “for homeless veterans [and] for working-class families.” These experiences have made him the doctor he is now: “I’ve cared for people who live and work in conditions that can be hard, if not harsh, and that work has led me to believe that we need a fundamentally different way of looking at healthcare.” 

He tells the stories of patients who are in and out of clinic, seeing multiple doctors but not getting the help that they need.

Then, the narrative shifts. A nurse asks a patient about their living conditions. In one case study, Dr. Manchanda describes a woman with chronic headaches who is finally able to tell a nurse that her home has mold. Dr. Manchanda then receives a report with this information regarding the patient’s lifestyle. When he enters the examination room, he sees a tell-tale sign of allergies–a crease on the bridge of the patient’s nose.

Effective deductive reasoning is directly correlated to the information that we have at our disposal. Knowing that this woman has mold allows the doctor to really see and, therefore, listen to his or her patient.

Dr. Manchanda describes the resulting process. He tells the patient that he is calling a specialist. My first reaction was great, throw her back into the system; but this time let her bounce between allergy specialists. Surprisingly, this specialist is none other than my favorite kind of healthcare professional–a Community Health Worker (CHW)!

The CHW goes to visit the patient’s home to identify the problem. From there, it is the CHW’s responsibility to mobilize a team including a public health worker and even a public health lawyer!

The CHW is the backbone of this amazing system but the change in this patient’s life started with someone in the doctor’s office asking “where do you live?”

The solution is so simple and there is ample evidence to support this approach. According to Dr. Manchada, “one’s zip code matters more than your genetic code. We’re also learning that zip code[s are] actually shaping our genetic code[s]. The science of epigenetics looks at those molecular mechanisms, those intricate ways in which our DNA is literally shaped, genes turned on and off based on [their] exposures to the environment, to where we live and to where we work. So it’s clear that these factors, these upstream issues, do matter.”

So not only does your environment affect your health but it can also literally tweak the chemical expression of your DNA.

The craziest part is that doctors know how important these upstream issues are but: “only one in five doctors said [that] they had any sense of confidence to address those issues, to improve health where it begins.” It is not an issue of information but one of narrative. Many doctors do not know a story in which they affect their patient’s living situation. Doctors are not empowered!

This is where HealthBegins becomes truly revolutionary. They train clinicians and other professionals on how to treat upstream issues. It is a matter of building confidence in our healthcare workers. HealthBegins shows interdisciplinary groups how to look at data together and mobilize forces to make a change in a sick person’s lifestyle in addition to providing education and necessary medication.

Finally, Dr. Manchanda makes a crucial point. Patients can ask these important questions themselves: “Are there barriers to health in my life? Doctor, are you willing to listen? What can we do together to improve my health where it begins?”

Upstream health is not just the job of doctors but the work of teams. All that doctors need to do is to recognize their role in putting systems in place where questions like “where do you live?” become routine. But, ultimately, the degree at the end of your name does not determine your ability to support such a system. In fact, upstream solutions need everyone from lawyers to nurses to family members. 

I will end with Dr. Manchada’s inspring words: “Health is not just a personal responsibility or phenomenon. Health is a common good. It comes from our personal investment in knowing that our lives matter, the context of where we live and [knowing that] where we work, eat, and sleep, matter, and that what we do for ourselves, we also should do for those whose living and working conditions again, can be hard, if not harsh.”

To read more about HealthBegins or watch Dr. Manchada’s ted talk click on the attached links.


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