What makes us get sick? Look upstream | Rishi Manchanda

For over a decade as a doctor,

I've cared for homeless veterans,

for working-class families.

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.

We simply need a healthcare system

that moves beyond just looking at the symptoms

that bring people into clinics,

but instead actually is able to look

and improve health where it begins.

And where health begins

is not in the four walls of a doctor's office,

but where we live

and where we work,

where we eat, sleep, learn and play,

where we spend the majority of our lives.

So what does this different approach to healthcare look like,

an approach that can improve health where it begins?

To illustrate this, I'll tell you about Veronica.

Veronica was the 17th patient

out of my 26-patient day

at that clinic in South Central Los Angeles.

She came into our clinic with a chronic headache.

This headache had been going on

for a number of years, and this particular episode

was very, very troubling.

In fact, three weeks before she came to visit us

for the first time, she went to an emergency room in Los Angeles.

The emergency room doctors said,

"We've run some tests, Veronica.

The results are normal, so here's some pain medication,

and follow up with a primary care doctor,

but if the pain persists or if it worsens,

then come on back."

Veronica followed those standard instructions

and she went back.

She went back not just once, but twice more.

In the three weeks before Veronica met us,

she went to the emergency room three times.

She went back and forth,

in and out of hospitals and clinics,

just like she had done in years past,

trying to seek relief but still coming up short.

Veronica came to our clinic,

and despite all these encounters with healthcare professionals,

Veronica was still sick.

When she came to our clinic, though, we tried a different approach.

Our approach started with our medical assistant,

someone who had a GED-level training

but knew the community.

Our medical assistant asked some routine questions.

She asked, "What's your chief complaint?"

"Headache."

"Let's get your vital signs" —

measure your blood pressure and your heart rate,

but let's also ask something equally as vital

to Veronica and a lot of patients like her

in South Los Angeles.

"Veronica, can you tell me about where you live?

Specifically, about your housing conditions?

Do you have mold? Do you have water leaks?

Do you have roaches in your home?"

Turns out, Veronica said yes to three of those things:

roaches, water leaks, mold.

I received that chart in hand, reviewed it,

and I turned the handle on the door

and I entered the room.

You should understand that Veronica,

like a lot of patients that I have the privilege of caring for,

is a dignified person, a formidable presence,

a personality that's larger than life,

but here she was

doubled over in pain sitting on my exam table.

Her head, clearly throbbing, was resting in her hands.

She lifted her head up,

and I saw her face, said hello,

and then I immediately noticed something

across the bridge of her nose,

a crease in her skin.

In medicine, we call that crease the allergic salute.

It's usually seen among children who have chronic allergies.

It comes from chronically rubbing one's nose up and down,

trying to get rid of those allergy symptoms,

and yet, here was Veronica, a grown woman,

with the same telltale sign of allergies.

A few minutes later, in asking Veronica some questions,

and examining her and listening to her,

I said, "Veronica, I think I know what you have.

I think you have chronic allergies,

and I think you have migraine headaches and some sinus congestion,

and I think all of those are related to where you live."

She looked a little bit relieved,

because for the first time, she had a diagnosis,

but I said, "Veronica, now let's talk about your treatment.

We're going to order some medications for your symptoms,

but I also want to refer you to a specialist, if that's okay."

Now, specialists are a little hard to find

in South Central Los Angeles,

so she gave me this look, like, "Really?"

And I said, "Veronica, actually, the specialist I'm talking about

is someone I call a community health worker,

someone who, if it's okay with you,

can come to your home

and try to understand what's going on

with those water leaks and that mold,

trying to help you manage those conditions in your housing that I think are causing your symptoms,

and if required, that specialist might refer you

to another specialist that we call a public interest lawyer,

because it might be that your landlord

isn't making the fixes he's required to make."

Veronica came back in a few months later.

She agreed to all of those treatment plans.

She told us that her symptoms had improved by 90 percent.

She was spending more time at work

and with her family and less time

shuttling back and forth between the emergency rooms of Los Angeles.

Veronica had improved remarkably.

Her sons, one of whom had asthma,

were no longer as sick as they used to be.

She had gotten better, and not coincidentally,

Veronica's home was better too.

What was it about this different approach we tried

that led to better care,

fewer visits to the E.R., better health?

Well, quite simply, it started with that question:

"Veronica, where do you live?"

But more importantly, it was that we put in place

a system that allowed us to routinely ask questions

to Veronica and hundreds more like her

about the conditions that mattered

in her community, about where health,

and unfortunately sometimes illness, do begin

in places like South L.A.

In that community, substandard housing

and food insecurity are the major conditions

that we as a clinic had to be aware of,

but in other communities it could be

transportation barriers, obesity,

access to parks, gun violence.

The important thing is, we put in place a system

that worked,

and it's an approach that I call an upstream approach.

It's a term many of you are familiar with.

It comes from a parable that's very common

in the public health community.

This is a parable of three friends.

Imagine that you're one of these three friends

who come to a river.

It's a beautiful scene, but it's shattered by the cries of a child,

and actually several children, in need of rescue in the water.

So you do hopefully what everybody would do.

You jump right in along with your friends.

The first friend says, I'm going to rescue those

who are about to drown,

those at most risk of falling over the waterfall.

The second friends says, I'm going to build a raft.

I'm going to make sure that fewer people

need to end up at the waterfall's edge.

Let's usher more people to safety

by building this raft,

coordinating those branches together.

Over time, they're successful, but not really,

as much as they want to be.

More people slip through, and they finally look up

and they see that their third friend

is nowhere to be seen.

They finally spot her.

She's in the water. She's swimming away from them

upstream, rescuing children as she goes,

and they shout to her, "Where are you going?

There are children here to save."

And she says back,

"I'm going to find out

who or what is throwing these children in the water."

In healthcare, we have that first friend —

we have the specialist,

we have the trauma surgeon, the ICU nurse,

the E.R. doctors.

We have those people that are vital rescuers,

people you want to be there when you're in dire straits.

We also know that we have the second friend —

we have that raft-builder.

That's the primary care clinician,

people on the care team who are there

to manage your chronic conditions,

your diabetes, your hypertension,

there to give you your annual checkups,

there to make sure your vaccines are up to date,

but also there to make sure that you have

a raft to sit on and usher yourself to safety.

But while that's also vital and very necessary,

what we're missing is that third friend.

We don't have enough of that upstreamist.

The upstreamists are the health care professionals

who know that health does begin

where we live and work and play,

but beyond that awareness, is able to mobilize

the resources to create the system

in their clinics and in their hospitals

that really does start to approach that,

to connect people to the resources they need

outside the four walls of the clinic.

Now you might ask, and it's a very obvious question

that a lot of colleagues in medicine ask:

"Doctors and nurses thinking about transportation and housing?

Shouldn't we just provide pills and procedures

and just make sure we focus on the task at hand?"

Certainly, rescuing people at the water's edge

is important enough work.

Who has the time?

I would argue, though, that if we were to use science as our guide,

that we would find an upstream approach is absolutely necessary.

Scientists now know that

the living and working conditions that we all

are part of

have more than twice the impact on our health

than does our genetic code,

and living and working conditions,

the structures of our environments,

the ways in which our social fabric is woven together,

and the impact those have on our behaviors,

all together, those have more than five times

the impact on our health

than do all the pills and procedures

administered by doctors and hospitals combined.

All together, living and working conditions

account for 60 percent of preventable death.

Let me give you an example of what this feels like.

Let's say there was a company, a tech startup

that came to you and said, "We have a great product.

It's going to lower your risk of death from heart disease."

Now, you might be likely to invest

if that product was a drug or a device,

but what if that product was a park?

A study in the U.K.,

a landmark study that reviewed the records

of over 40 million residents in the U.K.,

looked at several variables,

controlled for a lot of factors, and found that

when trying to adjust the risk of heart disease,

one's exposure to green space was a powerful influence.

The closer you were to green space,

to parks and trees,

the lower your chance of heart disease,

and that stayed true for rich and for poor.

That study illustrates what my friends in public health

often say these days:

that one's zip code matters more

than your genetic code.

We're also learning that zip code

is actually shaping our genetic code.

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 the 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.

They matter to our health,

and therefore our healthcare professionals should do something about it.

And yet, Veronica asked me

perhaps the most compelling question

I've been asked in a long time.

In that follow-up visit, she said,

"Why did none of my doctors

ask about my home before?

In those visits to the emergency room,

I had two CAT scans,

I had a needle placed in the lower part of my back

to collect spinal fluid,

I had nearly a dozen blood tests.

I went back and forth, I saw all sorts of people in healthcare,

and no one asked about my home."

The honest answer is that in healthcare,

we often treat symptoms without addressing

the conditions that make you sick in the first place.

And there are many reasons for that, but the big three

are first, we don't pay for that.

In healthcare, we often pay for volume and not value.

We pay doctors and hospitals usually

for the number of services they provide,

but not necessarily on how healthy they make you.

That leads to a second phenomenon that I call

the "don't ask, don't tell" approach

to upstream issues in healthcare.

We don't ask about where you live and where you work,

because if there's a problem there,

we don't know what to tell you.

It's not that doctors don't know these are important issues.

In a recent survey done in the U.S. among physicians,

over 1,000 physicians,

80 percent of them actually said that

they know that their patients' upstream problems

are as important as their health issues,

as their medical problems,

and yet despite that widespread awareness

of the importance of upstream issues,

only one in five doctors said they had

any sense of confidence to address those issues,

to improve health where it begins.

There's this gap between knowing

that patients' lives, the context of where they live and work,

matters, and the ability to do something about it

in the systems in which we work.

This is a huge problem right now,

because it leads them to this next question, which is,

whose responsibility is it?

And that brings me to that third point,

that third answer to Veronica's compelling question.

Part of the reason that we have this conundrum

is because there are not nearly enough upstreamists

in the healthcare system.

There are not nearly enough of that third friend,

that person who is going to find out

who or what is throwing those kids in the water.

Now, there are many upstreamists,

and I've had the privilege of meeting many of them,

in Los Angeles and in other parts of the country

and around the world,

and it's important to note that upstreamists

sometimes are doctors, but they need not be.

They can be nurses, other clinicians,

care managers, social workers.

It's not so important what specific degree

upstreamists have at the end of their name.

What's more important is that they all seem

to share the same ability to implement a process

that transforms their assistance,

transforms the way they practice medicine.

That process is a quite simple process.

It's one, two and three.

First, they sit down and they say,

let's identify the clinical problem

among a certain set of patients.

Let's say, for instance,

let's try to help children

who are bouncing in and out of the hospital

with asthma.

After identifying the problem, they then move on to that second step,

and they say, let's identify the root cause.

Now, a root cause analysis, in healthcare,

usually says, well, let's look at your genes,

let's look at how you're behaving.

Maybe you're not eating healthy enough.

Eat healthier.

It's a pretty simplistic

approach to root cause analyses.

It turns out, it doesn't really work

when we just limit ourselves that worldview.

The root cause analysis that an upstreamist brings

to the table is to say, let's look at the living

and the working conditions in your life.

Perhaps, for children with asthma,

it's what's happening in their home,

or perhaps they live close to a freeway with major air pollution

that triggers their asthma.

And perhaps that's what we should mobilize our resources to address,

because that third element, that third part of the process,

is that next critical part of what upstreamists do.

They mobilize the resources to create a solution,

both within the clinical system,

and then by bringing in people from public health,

from other sectors, lawyers,

whoever is willing to play ball,

let's bring in to create a solution that makes sense,

to take those patients who actually have clinical problems

and address their root causes together

by linking them to the resources you need.

It's clear to me that there are so many stories

of upstreamists who are doing remarkable things.

The problem is that there's just not nearly enough of them out there.

By some estimates, we need one upstreamist

for every 20 to 30 clinicians in the healthcare system.

In the U.S., for instance, that would mean

that we need 25,000 upstreamists

by the year 2020.

But we only have a few thousand upstreamists out there right now, by all accounts,

and that's why, a few years ago, my colleagues and I

said, you know what, we need to train

and make more upstreamists.

So we decided to start an organization

called Health Begins,

and Health Begins simply does that:

We train upstreamists.

And there are a lot of measures that we use for our success,

but the main thing that we're interested in

is making sure that we're changing

the sense of confidence,

that "don't ask, don't tell" metric among clinicians.

We're trying to make sure that clinicians,

and therefore their systems that they work in

have the ability, the confidence

to address the problems in the living

and working conditions in our lives.

We're seeing nearly a tripling

of that confidence in our work.

It's remarkable,

but I'll tell you the most compelling part

of what it means to be working

with upstreamists to gather them together.

What is most compelling is that every day,

every week, I hear stories just like Veronica's.

There are stories out there of Veronica

and many more like her,

people who are coming to the healthcare system

and getting a glimpse of what it feels like

to be part of something that works,

a health care system that stops bouncing you back and forth

but actually improves your health,

listens to you who you are,

addresses the context of your life,

whether you're rich or poor or middle class.

These stories are compelling because

not only do they tell us that we're this close

to getting the healthcare system that we want,

but that there's something that we can all do to get there.

Doctors and nurses can get better at asking

about the context of patients' lives,

not simply because it's better bedside manner,

but frankly, because it's a better standard of care.

Healthcare systems and payers

can start to bring in public health agencies

and departments and say,

let's look at our data together.

Let's see if we can discover some patterns in our data about our patients' lives

and see if we can identify an upstream cause,

and then, as importantly, can we align the resources

to be able to address them?

Medical schools, nursing schools,

all sorts of health professional education programs

can help by training the next generation of upstreamists.

We can also make sure that these schools

certify a backbone of the upstream approach,

and that's the community health worker.

We need many more of them in the healthcare system

if we're truly going to have it be effective,

to move from a sickcare system

to a healthcare system.

But finally, and perhaps most importantly,

what do we do? What do we do as patients?

We can start by simply going to our doctors

and our nurses, to our clinics,

and asking, "Is there something in where I live

and where I work that I should be aware of?"

Are there barriers to health that I'm just not aware of,

and more importantly, if there are barriers

that I'm surfacing, if I'm coming to you

and I'm saying I think have a problem with

my apartment or at my workplace

or I don't have access to transportation,

or there's a park that's way too far,

so sorry doctor, I can't take your advice

to go and jog,

if those problems exist,

then doctor, are you willing to listen?

And what can we do together

to improve my health where it begins?

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.

It comes from our personal investment in knowing

that our lives matter,

the context of where we live and 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.

We can all invest in making sure that we improve

the allocation of resources upstream,

but at the same time work together

and show that we can move healthcare

upstream.

We can improve health where it begins.

Thank you.

(Applause)