Text: Julie Zaugg
Photo: DR

Rishi Manchanda: “Health is too rarely perceived as a group phenomenon”

Champions an “upstream” approach to medicine, suggesting that healthcare take into account where and how patients live.

«The Upstream Doctors: Medical Innovators Track Sickness to Its Source», TED Conferences, 2013.

Rishi Manchanda has devoted his entire career to understanding social and environmental factors that affect health. The water we drink, the air we breathe, the job we do.

Rishi Manchanda has worked for a decade as a doctor in the disadvantaged neighbourhood of South Central Los Angeles. He has developed a community approach to healthcare that aims to act upstream to prevent disease before it appears.

IN VIVO You invented the concept of the healthcare professional who focuses on where health begins, the “upstreamist”. What is it about?

RISHI MANCHANDA The term comes from a parable. Three friends come to a river that leads to a waterfall. It’s a beautiful setting, but they soon notice that the water is full of children who are drowning. The three friends jump into the river. The first tries to save the children who are in the greatest danger, those closest to the waterfall. The second friend starts building a raft from piece of wood. And the third friend starts swimming away, upstream. “What are you doing? Come back and help us!” the other friends shout. “No, I’m going to find out what’s throwing these children in the water,” the third friend answers. That’s exactly what upstreamist healthcare professionals do. They look for the root cause, the social or environmental factors that have brought about the disease. All too often, the medical system only treats the patient’s symptoms. But we should also look at the conditions that impact our health, those which are often less obvious at first glance.

IV What are the hidden causes?

RM There are two kinds. First, the patient’s living and working conditions. These include housing conditions, where they live, and the environment where they work, eat, sleep and play. Is there access to parks or green spaces? Are there leaks in their home? Is there mould? Do they live close to a motorway? Second, there are social or political causes. They are the invisible government structures, factors that determine how resources are allocated in society, to rich and poor.


Rishi Manchanda is a leading figure in upstream healthcare in the United States. He is the president and founder of Health Begins, a social network where clinicians can exchange ideas on prevention and upstream causes of illnesses. He is the medical director of a veterans’ clinic within the Greater Los Angeles Healthcare System. In 2013, Rishi Manchanda published The Upstream Doctors, in which he lays out his firm belief that we need to understand and address the causes and not just the symptoms of a disease.

IV Can you give us an example of how environmental factors affect people’s health?

RM A study of 30 million people conducted in the United Kingdom focused on the correlation between exposure to green space and the risk of heart disease. It found that the closer people are to green space, the lower their chance of developing heart disease, regardless of income and education.

IV How does social equality shape our health?

RM Food insecurity is generally perceived as a third-world problem related to hunger. But it also exists in developed societies when people don’t have access to stores that sell fresh, healthy products, or if they can’t afford to buy food and have to skip meals or eat cheap fast food. Food insecurity affects an estimated one in seven Americans, including 17 million children. For diabetics, food insecurity can have drastic effects and send them straight to the hospital. Skipping a meal makes their blood sugar level drop, and if they eat high-calorie, energy-dense fast food or foods containing high-fructose corn syrup, their blood sugar level is too high. Living in a constant state of hunger prevents proper glucose synthesis. The body is completely thrown off. In California, low-income individuals with diabetes are 27% more likely to be admitted to the hospital at the end of the month, when their budget starts to run out.

IV When did medicine realise the effect that these social and environmental factors can have on people’s health?

RM We suspected that these correlations have been around for a long time, but had no scientific research to back them up. The corpus of research in the area has grown massively over the past 20 years. One of the major advances comes from epigenetics, a science that looks at the link between environment and gene expression. We now know that these transformations can even be passed on to the next generation.

IV How can we detect the upstream causes of disease?

RM We can use epidemiological research or geomapping tools to detect suspicious disease clusters. But we first have to communicate with the patient and ask the right questions. For example, when a lot of people are coming in with asthma, healthcare practitioners should ask about their exposure to allergens, such as mould or dust, second-hand smoke, or if they live near a motorway with high air pollution. All these factors can trigger asthma. A doctor should also ask the patient’s opinion about what might have caused the illness. This self-analysis can often deliver surprisingly relevant results. But too often, doctors are trapped in a one-way approach to practising medicine. They talk but don’t listen.

IV Why is there such a lack of interest?

RM Doctors face several obstacles. First, how healthcare is financed. Doctors are not encouraged to look for the root cause of disease because we don’t pay them to do that. We pay them for the number of services they provide, not the quality of those services. Second, regulations often prevent information from being shared between environmental or housing authorities and the medical world. Sharing this information could help detect and explain concentrations of sick people. Lastly, current medical practice is to focus on the individual rather than the group, putting the treatment of symptoms first, before looking at the causes of the illness. Health is not perceived as a group phenomenon. Doctors rarely belong to the same social or ethnic categories as their patients. This lack of diversity blinds them to the socio-economic forces at work that could be making their patients sick.

“A doctor should also ask the patient’s opinion about what might have caused the illness. This self-analysis can often deliver surprisingly relevant results.”

IV What can they do to act upstream?

RM Doctors must be careful not to become social workers. That’s not their role. However, they can form healthcare teams of nurses, social workers, community representatives, etc. I worked at a homeless clinic in Los Angeles, and we involved public interest lawyers in their care, because we realised that patients’ inability to find a home was one of the main obstacles preventing them from becoming healthier. That type of work in a multidisciplinary team can be liberating and gratifying for physicians, even if it means relinquishing some of their power.

IV Are there countries or regions in the world where these practices are already a reality?

RM In Kerala, India, the healthcare services take a very community-based approach to medicine. Some aspects of the healthcare system in Costa Rica and Cuba factor in upstream determinants. The NGO Partners in Health in Haiti also take this approach. There are many interesting local examples in the United States, such as Montefiore Medical Centre in the Bronx or the Blueprint for Health initiative in Vermont.

IV How can new technologies be used in upstream medicine?

RM They’re not a solution in themselves but are an important tool. Electronic health records can be used to store information provided by the patient about his or her living and working conditions. Big data techniques can be applied to analyse these records and spot trends or clusters of sick people. Self-monitoring devices [Editor’s note – e.g. bracelets and smart watches that track the wearer’s vital signs] can help doctors identify what’s wrong with a patient. Online platforms could be created – like a Yelp for health – that community members use to find the resources they need to stay healthy [Editor’s note – social services, pest control professionals, shelters for abused women, ongoing training centres] as easily as a restaurant.

IV Should this type of medicine be integrated more into medical training?

RM The education authorities still think of community health as the poor relative of medicine, as a less prestigious career than surgery, for example. But a new generation of practitioners is emerging, who are aware of the importance of social and environmental determinants to health. I’m both frustrated by the current way doctors are trained and hopeful about its future. In the United States we ideally need 24,000 upstreamist doctors by 2020, i.e., one out of 20 or 30 traditional clinicians. Choosing a name was the first step towards recognition of the field. That’s why I invented the term “upstreamist”. ⁄