Rowing Together: How Public Health Supports the “Upstream” Doctor

by Brian C. Castrucci

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, MD, 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?

This post originally appeared in the Huffington Post.

The Next Transformation in American Health Care

by Brian C. Castrucci

There’s a crisis in American healthcare that goes far beyond the debate over healthcare finance reform or the implementation of the Affordable Care Act.

If money could solve today’s most pressing medical problems, the United States – which spends more than any other country on healthcare – would have the best health outcomes in the world. Despite all that we spend (nearly $3 trillion in 2011), growth in life expectancy in the US has slowed compared to other economically developed countries, trailing nations like Slovenia and Denmark, which spend substantially less than the US on healthcare.

The crisis in American healthcare today is the ascendance of chronic conditions, which can’t be fixed with a pill or procedure. We are seeing a transition from predominantly biological, physiological, and microbial origins of disease to diseases caused by social and environmental conditions. As a result, clinicians can invest hours of treatment and test a variety of different pharmacological combinations with limited, if any, change in outcomes.

The simple truth is that our traditional model of healthcare delivery doesn’t work anymore. It was designed to respond to acute illnesses like polio and typhoid, not to address causes of disease that occur far beyond the clinic walls. No amount of healthcare reform focusing on healthcare financing and organizational inefficiencies can fix the root problem in our medical system.

We Need a Medical Cultural Revolution

There is growing recognition that individual health is nearly inseparable from community health. We need a transformation of American healthcare that recognizes this reality and works to align clinical medicine and public health as partners in a collaborative effort to improve population health.

In the past, many of our triumphs over disease — for example, polio, smallpox, and malaria — have been the result of medical breakthroughs providing clinicians with a new drug to eradicate an illness. As we look at our current healthcare challenges, laboratories no longer offer the possibility for a magic bullet.

There is no treatment, pill, or vaccine to address the lack of fresh fruits and vegetables to support a healthy diet, limited options for physical activity, exposures to environmental toxins, or the disproportionate distribution of alcohol and tobacco advertising and outlets. These are the community-level drivers of the chronic diseases that plague population health and are responsible for much of the healthcare spending in the US.

Health care reforms, including the Patient Accountability and Affordable Care Act, focus on needed changes to healthcare financing and reimbursement as well as increased access to healthcare. These are worthwhile goals, but they will not lead to the transformation needed in American health. Integrating the efforts of public health and clinical medicine will allow us to make the next vital transformation in healthcare to ensure that we have a system that acts upon the undeniable link between the individual and the community.

This post originally appeared in the Huffington Post.

“Practical Playbook” Aims to Improve Population Health, Cut Health Care Costs

For decades, the medical and public health communities have struggled to stem the rise of illnesses that have led to a dramatic decline in population health. Today, chronic diseases such as asthma, obesity, heart disease, and diabetes have replaced acute diseases like polio and smallpox as the leading drivers of illness in this country.

This trend, which appears to have been initiated in the early to mid-twentieth century, is not only leading to a lower quality of life and reduced economic productivity, but is a primary contributor to this country’s astronomical health care costs. Chronic diseases account for 80 percent of all health care costs today compared to only 20 percent in 1900.

In accordance with generations of studies citing a need for more effective preventive care, the de Beaumont Foundation, Duke Community and Family Medicine, and the Centers for Disease Control and Prevention have created a new initiative – “Practical Playbook: Public Health & Primary Care Together” – to support the project-based integration of public health and primary care.

The Practical Playbook is designed to achieve three objectives: to improve population health, better manage illness (especially chronic disease), and mitigate healthcare costs. In practice, it gives local health administrators, public health officials, and primary care providers the means to offer more comprehensive health care both within and beyond a clinical context.

“We developed the Practical Playbook based upon years of research and anecdotal evidence that show that when local health departments and primary care providers work together, they can help communities get healthier and help both patients and insurers save on preventable illnesses,” said Dr. Lloyd Michener, Professor and Chair of Duke Community and Family Medicine. “Our goal now is to take these local successes and apply them on a national scale.”

Consider chronic asthma, which is growing every year and at last count (in 2007), cost the United States $56 billion in medical care, lost school and work days, and early deaths. Today, the best that primary care providers can do is treat an individual patient’s repeat episodes or “flare-ups.” If there were an ongoing collaboration with the local health department, however, public health officials could collect real time data from multiple practices and emergency rooms and compile information that would identify asthma clusters. This would allow the health department to take immediate action to investigate whether there is an environmental cause that can be addressed to control the ongoing cases and to prevent the development of new ones.

To promote this kind of public health and primary care collaboration, the Practical Playbook initiative has developed a web-based tool in three parts. Part 1, “Learn,” explains the theoretical background of public health and primary care integration. Part 2, “Do,” outlines action steps for starting your own collaborative project to engage with a health concern in your community such as heart disease, obesity, or asthma. Part 3, “Share,” provides case studies of successful collaborative projects, complete with direct contacts to the project leads.

“Despite years of conferences, seminars, and reports from the medical community lauding the merits of public health and primary care integration, we have yet to see any meaningful progress towards improving population health,” said Dr. James Sprague, CEO of the de Beaumont Foundation. “Facilitating collaboration between primary care providers and local health departments is a crucial element in addressing the social determinants of health and working long term to make all Americans live longer, healthier lives.”

Dr. Denise Koo, Senior Advisor for Health Systems, Centers for Disease Control and Prevention added, “The Practical Playbook will be a game-changing tool for helping communities deal with the unchecked rise of chronic diseases like obesity, diabetes, and heart disease. It will be a cornerstone in our efforts to shift to a system focused on keeping our communities healthy rather than putting a Band-Aid on after they get sick.”

To learn more about the Practical Playbook, visit

de Beaumont Foundation Partners with ASTHO to Identify Cross-Cutting Public Health Workforce Training Needs

The de Beaumont Foundation and the Association of State and Territorial Health Officials (ASTHO) recently convened 31 national public health leadership groups to collectively assess the priorities, needs, and characteristics of the governmental public health workforce. The ASTHO/de Beaumont Public Health Workforce Strategy meeting is part of a multi-year commitment on the part of both organizations to identify the top strategic challenges and opportunities that the current and future public health workforce must address. This is the first time that representatives from these national public health organizations from all levels and functions of the governmental public health workforce have come together to discuss cross-cutting training needs.

“Categorical public health funding drives silos in public health practice and leads to inefficiency and duplication. This project was built on the belief that public health is more than just the sum of its silos,” says James B. Sprague, MD, Chairman and CEO of the de Beaumont Foundation. “We believe there are foundational public health workforce needs that can only be identified by looking across our national landscape.”

Organizers challenged the 15 ASTHO affiliates, eight ASTHO peer groups, two federal agencies, and other partners in attendance to look beyond their individual priorities and think about universal public health workforce needs. Twenty-six workforce training needs were identified through pre-meeting interviews; from this list, systems thinking, communicating persuasively, and change management/flexibility were identified as top priorities during the meeting.

“The information gained from this meeting and the conclusion of this larger project will help to enhance coordination among ASTHO, its affiliates and peer networks, as well as key partners in order to help foster a stronger learning culture within health departments and stimulate more research on workforce development,” said Paul E. Jarris, MD, MBA, executive director of ASTHO. “In an environment of growing demands and diminishing resources we need to focus our workforce development efforts on trainings that will have the most impact for the most people.”

Reaching agreement around these critical priorities sets a clear agenda to create trainings and tools for a stronger public health workforce. Building on the work performed during the meeting, an expert panel has been identified to develop and implement an innovative, national survey to measure the strengths, weaknesses, attitudes, skills, and beliefs of the public health workforce. The final product will be a full and detailed report on the country’s current public health workforce and an effective roadmap for the field’s future development.


de Beaumont Foundation Partners with Duke University, CDC to Create Public Health and Primary Care Together: A Practical Playbook

The de Beaumont Foundation has announced a $1 million grant to the Department of Community and Family Medicine at Duke University to help develop Public Health and Primary Care Together: A Practical Playbook, an interactive web-based resource for the integration of primary care and public health.

“While there has been conceptual support for and discussion of the integration of primary care and
public health, a practical translation with tools and strategies to support efforts to integrate has not
been available,” said James Sprague, MD, Chairman and CEO of the de Beaumont Foundation. “The Practical Playbook addresses this need.”

In recent years, American health has suffered increasingly from chronic diseases. That shift, coupled with health care cost increases, indicates a need for a new model for health beyond healthcare delivery in the United States. In 2012, the Institute of Medicine published Primary Care and Public Health: Exploring Integration to Improve Population Health. According to this report, the traditional division between public health and primary care has hindered efforts to improve population health. By increasing collaboration between the public health and primary care sectors, individuals can receive the resources and services they need through effective and engaged community-based systems. Public Health and Primary Care Together: A Practical Playbook will offer a comprehensive and practical approach to that goal and promises improvement in population health by transforming the relationship between the public health and primary care sectors.

The concept of the Playbook was developed with Duke University, the Centers for Disease Control and Prevention, and the de Beaumont Foundation. This is the first grant the Foundation has made to the university.

“This project has the potential to improve the health of diverse populations by improving the ability of
primary care and public health to partner in improving the health of the communities they both serve,” said J. Lloyd Michener, MD, Chair of the Department of Community and Family Medicine at Duke University & Director of the Duke Center for Community Research. Dr. Michener will serve as the project’s principal investigator. Denise Koo, MD, MPH, Director of Scientific Education and Professional Development at the CDC, commented, “Our public health and our health care partners are equally eager to get hold of this playbook so they can synergize their efforts caring for communities.”

Public Health and Primary Care Together: A Practical Playbook will be developed over two years,
with the second year devoted to broad implementation.