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What Is Upstream Healthcare?

An approach to care that examines and addresses root causes rather than symptoms can improve long-term outcomes and decrease healthcare costs.
Upstream healthcare
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Upstream healthcare is any health intervention that stems from a philosophy rooted in one simple question: “What would it take for this problem to never happen again?”

Here’s a common analogy: Imagine walking along a stream and seeing people floating down, nearly drowning. Of course, your first thought is to run to shore and pull them out. You feel good about it —you've saved them from drowning, after all — but people keep coming down the river. As you exhaust yourself pulling them out, you begin wondering why so many people are drowning in this water anyway. (Upstream healthcare, in this analogy, begins with this curiosity.) As you walk up the bank, you discover that a safety fence meant to keep people from falling into the water is missing.

Healthcare as we know it today would be standing at the water’s edge and hauling half-drowned people out of the water. Upstream healthcare is building the safety fence so that people don’t fall into the water at all.

Addressing root causes of poor health

In real terms, this might look like people from a particular community repeatedly coming into the ED with gunshot wounds, or persistent unstable disease. Rather than treating the wounds and disease and sending people back where they came from, we can look upstream and ask, “What would it take for this never to happen again?”

Rather than treating the wounds and disease and sending people back where they came from, we can look upstream and ask, "What would it take for this never to happen again?" Click To Tweet

By taking a closer look at the environment in which these situations happen, we may likely find that this community lacks opportunities for economic mobility, or poor transit, which means people can't get back and forth to jobs. There is no access to healthy, affordable food. The education system is really poor. The housing is terrible and there's not enough of it anyway, and people are moving in and displacing longtime community members. People living in public housing in the community have restrictions on maximum earned income, which prevents them from accepting better jobs and earning enough to move out of public housing. Essentially, there is no support in this community that is seeing recurring illness, injury, and disease.

Chronic, daily stresses of poverty like lower earning potential and lower educational attainment have been associated with community violence and other health inequities, including lower life expectancies, higher rates of homicide, and worse health outcomes overall. This trajectory extends to their children, who are the beneficiaries of the resources their parents have.

Without disruption, these cycles of social inequities and the resulting health disparities continue.

Healthcare as we know it today is hauling half-drowned people out of the water. Upstream healthcare is building a safety fence so that people don't fall into the water at all. Click To Tweet

To improve the health and outcomes of our communities, health systems should start thinking in terms of root causes rather than the symptoms that bring patients through our doors. Many patients come from communities that have been disinvested in for decades, which has created structural barriers and gaps in domains of thriving: income, financial stability, and wealth building; home and housing; healthy, affordable foods; education and job training. These domains have direct correlations with health.

Enacting an upstream approach to address social determinants of health

Simply put, upstream healthcare is any approach to disrupt these structural barriers and to transform a person’s quality of life and health outcomes. By improving factors such as income, financial stability, education, food access, and housing stability, we can change the corollaries in health outcomes. By mitigating and eliminating the gaps that create stress, predictable worse health outcomes, and community violence, we can contribute to a sustainable improved quality of life trajectory for our patients.

Healthcare systems can use our resources not only for treating injury and illness, but for upstream innovation and problem solving. We can build long-term social impact through advocacy for equitable policies and investments in housing, local business and community, economic mobility, and healthy foods that support healthy, thriving communities.

Financially and morally, the U.S. health system can no longer afford to see our patients drowning — this is our best opportunity to make progress.


Thea James, MD


Thea James is an emergency medicine physician and the associate chief medical officer at Boston Medical Center. A long-time supporter of upstream healthcare, she is also the hospital's VP of mission and founder of the Violence Intervention Advocacy Program.