ABOUT THE SPEAKER
Rishi Manchanda - Physician
Rishi Manchanda is an "upstreamist." A physician and public health innovator, he aims to reinvigorate primary care by teaching doctors to think about—and treat—the social and environmental conditions that often underly sickness.

Why you should listen

For a decade, Rishi Manchanda has worked as a doctor in South Central Los Angeles, treating patients who live and work in harsh conditions. He has worked at the Venice Family Clinic, one of the largest free clinics in the United States. He was the first director of social medicine at the St. John’s Well Child and Family Center in Compton, where he and his team provided high quality primary care to low-income families in the area. Currently, he is the medical director of a veterans’ clinic within the Greater Los Angeles Healthcare System, which he refers to as an “intensive caring unit.” He tells the National Health Corps Services, “The moment when a patient switches from despair to hopefulness is the greatest part of my service.” 

Manchanda is the author of the TED Book The Upstream Doctors, in which he looks at how health begins at home and in the workplace, with the social and environmental factors of our everyday lives. He shows how the future of our healthcare system depends on “upstreamists,” the doctors, nurses and other healthcare practitioners who look for the root cause of illness rather than just treating the symptoms.

Manchanda is the president and founder of Health Begins, a social network that teaches and empowers clinicians to improve health where it begins—in patients’ home and work environments. He also founded RxDemocracy, a nonpartisan coalition created to register voters in healthcare clinics. He serves on the board of the National Physicians Alliance, as well as on the board of Physicians for Social Responsibility in Los Angeles.

More profile about the speaker
Rishi Manchanda | Speaker | TED.com
TEDSalon NY2014

Rishi Manchanda: What makes us get sick? Look upstream

Filmed:
1,843,333 views

Rishi Manchanda has worked as a doctor in South Central Los Angeles for a decade, where he’s come to realize: His job isn’t just about treating a patient’s symptoms, but about getting to the root cause of what is making them ill—the “upstream" factors like a poor diet, a stressful job, a lack of fresh air. It’s a powerful call for doctors to pay attention to a patient's life outside the exam room.
- Physician
Rishi Manchanda is an "upstreamist." A physician and public health innovator, he aims to reinvigorate primary care by teaching doctors to think about—and treat—the social and environmental conditions that often underly sickness. Full bio

Double-click the English transcript below to play the video.

00:12
For over a decade as a doctor,
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I've cared for homeless veterans,
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for working-class families.
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I've cared for people who
live and work in conditions
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that can be hard, if not harsh,
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and that work has led me to believe
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that we need a fundamentally different way
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of looking at healthcare.
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We simply need a healthcare system
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that moves beyond just looking at the symptoms
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that bring people into clinics,
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but instead actually is able to look
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and improve health where it begins.
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And where health begins
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is not in the four walls of a doctor's office,
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but where we live
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and where we work,
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where we eat, sleep, learn and play,
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where we spend the majority of our lives.
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So what does this different
approach to healthcare look like,
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an approach that can improve health where it begins?
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To illustrate this, I'll tell you about Veronica.
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Veronica was the 17th patient
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out of my 26-patient day
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at that clinic in South Central Los Angeles.
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She came into our clinic with a chronic headache.
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This headache had been going on
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for a number of years, and this particular episode
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was very, very troubling.
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In fact, three weeks before she came to visit us
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for the first time, she went to an
emergency room in Los Angeles.
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The emergency room doctors said,
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"We've run some tests, Veronica.
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The results are normal, so
here's some pain medication,
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and follow up with a primary care doctor,
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but if the pain persists or if it worsens,
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then come on back."
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Veronica followed those standard instructions
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and she went back.
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She went back not just once, but twice more.
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In the three weeks before Veronica met us,
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she went to the emergency room three times.
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She went back and forth,
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in and out of hospitals and clinics,
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just like she had done in years past,
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trying to seek relief but still coming up short.
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Veronica came to our clinic,
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and despite all these encounters
with healthcare professionals,
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Veronica was still sick.
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When she came to our clinic, though,
we tried a different approach.
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Our approach started with our medical assistant,
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someone who had a GED-level training
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but knew the community.
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Our medical assistant asked some routine questions.
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She asked, "What's your chief complaint?"
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"Headache."
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"Let's get your vital signs" —
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measure your blood pressure and your heart rate,
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but let's also ask something equally as vital
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to Veronica and a lot of patients like her
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in South Los Angeles.
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"Veronica, can you tell me about where you live?
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Specifically, about your housing conditions?
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Do you have mold? Do you have water leaks?
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Do you have roaches in your home?"
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Turns out, Veronica said yes
to three of those things:
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roaches, water leaks, mold.
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I received that chart in hand, reviewed it,
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and I turned the handle on the door
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and I entered the room.
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You should understand that Veronica,
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like a lot of patients that I have
the privilege of caring for,
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is a dignified person, a formidable presence,
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a personality that's larger than life,
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but here she was
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doubled over in pain sitting on my exam table.
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Her head, clearly throbbing, was resting in her hands.
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She lifted her head up,
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and I saw her face, said hello,
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and then I immediately noticed something
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across the bridge of her nose,
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a crease in her skin.
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In medicine, we call that crease the allergic salute.
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It's usually seen among children
who have chronic allergies.
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It comes from chronically rubbing
one's nose up and down,
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trying to get rid of those allergy symptoms,
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and yet, here was Veronica, a grown woman,
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with the same telltale sign of allergies.
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A few minutes later, in asking
Veronica some questions,
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and examining her and listening to her,
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I said, "Veronica, I think I know what you have.
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I think you have chronic allergies,
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and I think you have migraine
headaches and some sinus congestion,
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and I think all of those are
related to where you live."
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She looked a little bit relieved,
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because for the first time, she had a diagnosis,
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but I said, "Veronica, now let's
talk about your treatment.
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We're going to order some
medications for your symptoms,
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but I also want to refer you to
a specialist, if that's okay."
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Now, specialists are a little hard to find
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in South Central Los Angeles,
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so she gave me this look, like, "Really?"
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And I said, "Veronica, actually,
the specialist I'm talking about
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is someone I call a community health worker,
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someone who, if it's okay with you,
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can come to your home
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and try to understand what's going on
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with those water leaks and that mold,
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trying to help you manage those conditions in your housing that I think are causing your symptoms,
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and if required, that specialist might refer you
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to another specialist that we
call a public interest lawyer,
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because it might be that your landlord
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isn't making the fixes he's required to make."
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Veronica came back in a few months later.
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She agreed to all of those treatment plans.
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She told us that her symptoms
had improved by 90 percent.
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She was spending more time at work
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and with her family and less time
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shuttling back and forth between
the emergency rooms of Los Angeles.
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Veronica had improved remarkably.
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Her sons, one of whom had asthma,
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were no longer as sick as they used to be.
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She had gotten better, and not coincidentally,
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Veronica's home was better too.
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What was it about this different approach we tried
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that led to better care,
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fewer visits to the E.R., better health?
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Well, quite simply, it started with that question:
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"Veronica, where do you live?"
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But more importantly, it was that we put in place
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a system that allowed us to routinely ask questions
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to Veronica and hundreds more like her
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about the conditions that mattered
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in her community, about where health,
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and unfortunately sometimes illness, do begin
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in places like South L.A.
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In that community, substandard housing
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and food insecurity are the major conditions
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that we as a clinic had to be aware of,
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but in other communities it could be
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transportation barriers, obesity,
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access to parks, gun violence.
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The important thing is, we put in place a system
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that worked,
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and it's an approach that I call an upstream approach.
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It's a term many of you are familiar with.
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It comes from a parable that's very common
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in the public health community.
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This is a parable of three friends.
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Imagine that you're one of these three friends
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who come to a river.
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It's a beautiful scene, but it's
shattered by the cries of a child,
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and actually several children,
in need of rescue in the water.
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So you do hopefully what everybody would do.
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You jump right in along with your friends.
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The first friend says, I'm going to rescue those
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who are about to drown,
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those at most risk of falling over the waterfall.
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The second friends says,
I'm going to build a raft.
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I'm going to make sure that fewer people
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need to end up at the waterfall's edge.
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Let's usher more people to safety
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by building this raft,
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coordinating those branches together.
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Over time, they're successful, but not really,
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as much as they want to be.
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More people slip through, and they finally look up
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and they see that their third friend
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is nowhere to be seen.
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They finally spot her.
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She's in the water. She's swimming away from them
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upstream, rescuing children as she goes,
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and they shout to her, "Where are you going?
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There are children here to save."
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And she says back,
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"I'm going to find out
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who or what is throwing these children in the water."
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In healthcare, we have that first friend —
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we have the specialist,
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we have the trauma surgeon, the ICU nurse,
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the E.R. doctors.
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We have those people that are vital rescuers,
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people you want to be there
when you're in dire straits.
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We also know that we have the second friend —
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we have that raft-builder.
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That's the primary care clinician,
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people on the care team who are there
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to manage your chronic conditions,
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your diabetes, your hypertension,
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there to give you your annual checkups,
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there to make sure your vaccines are up to date,
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but also there to make sure that you have
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a raft to sit on and usher yourself to safety.
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But while that's also vital and very necessary,
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what we're missing is that third friend.
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We don't have enough of that upstreamist.
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The upstreamists are the health care professionals
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who know that health does begin
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where we live and work and play,
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but beyond that awareness, is able to mobilize
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the resources to create the system
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in their clinics and in their hospitals
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that really does start to approach that,
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to connect people to the resources they need
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outside the four walls of the clinic.
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Now you might ask, and it's
a very obvious question
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that a lot of colleagues in medicine ask:
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"Doctors and nurses thinking
about transportation and housing?
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Shouldn't we just provide pills and procedures
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and just make sure we focus on the task at hand?"
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Certainly, rescuing people at the water's edge
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is important enough work.
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Who has the time?
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I would argue, though, that if we
were to use science as our guide,
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that we would find an upstream
approach is absolutely necessary.
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Scientists now know that
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the living and working conditions that we all
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are part of
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have more than twice the impact on our health
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than does our genetic code,
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and living and working conditions,
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the structures of our environments,
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the ways in which our social fabric is woven together,
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and the impact those have on our behaviors,
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all together, those have more than five times
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the impact on our health
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than do all the pills and procedures
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administered by doctors and hospitals combined.
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All together, living and working conditions
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account for 60 percent of preventable death.
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Let me give you an example of what this feels like.
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Let's say there was a company, a tech startup
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that came to you and said, "We have a great product.
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It's going to lower your risk
of death from heart disease."
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Now, you might be likely to invest
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if that product was a drug or a device,
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but what if that product was a park?
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A study in the U.K.,
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a landmark study that reviewed the records
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of over 40 million residents in the U.K.,
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looked at several variables,
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controlled for a lot of factors, and found that
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when trying to adjust the risk of heart disease,
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one's exposure to green
space was a powerful influence.
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The closer you were to green space,
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to parks and trees,
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the lower your chance of heart disease,
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and that stayed true for rich and for poor.
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That study illustrates what my friends in public health
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often say these days:
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that one's zip code matters more
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than your genetic code.
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We're also learning that zip code
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is actually shaping our genetic code.
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The science of epigenetics looks
at those molecular mechanisms,
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those intricate ways in which
our DNA is literally shaped,
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genes turned on and off
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based on the exposures to the environment,
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to where we live and to where we work.
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So it's clear that these factors,
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these upstream issues, do matter.
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They matter to our health,
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and therefore our healthcare professionals
should do something about it.
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And yet, Veronica asked me
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perhaps the most compelling question
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I've been asked in a long time.
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In that follow-up visit, she said,
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"Why did none of my doctors
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ask about my home before?
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In those visits to the emergency room,
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I had two CAT scans,
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I had a needle placed in the lower part of my back
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to collect spinal fluid,
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I had nearly a dozen blood tests.
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I went back and forth, I saw
all sorts of people in healthcare,
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2654
10:30
and no one asked about my home."
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4285
10:34
The honest answer is that in healthcare,
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1738
10:36
we often treat symptoms without addressing
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10:38
the conditions that make you sick in the first place.
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3120
10:41
And there are many reasons for that, but the big three
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1844
10:43
are first, we don't pay for that.
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4600
10:47
In healthcare, we often pay
for volume and not value.
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3385
10:51
We pay doctors and hospitals usually
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1788
10:52
for the number of services they provide,
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1980
10:54
but not necessarily on how healthy they make you.
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3299
10:58
That leads to a second phenomenon that I call
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646219
2311
11:00
the "don't ask, don't tell" approach
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1380
11:01
to upstream issues in healthcare.
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2574
11:04
We don't ask about where you
live and where you work,
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1744
11:06
because if there's a problem there,
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1225
11:07
we don't know what to tell you.
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2896
11:10
It's not that doctors don't know
these are important issues.
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2820
11:13
In a recent survey done in the U.S. among physicians,
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1871
11:15
over 1,000 physicians,
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1891
11:16
80 percent of them actually said that
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664931
1812
11:18
they know that their patients' upstream problems
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11:20
are as important as their health issues,
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1887
11:22
as their medical problems,
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1692
11:24
and yet despite that widespread awareness
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2361
11:26
of the importance of upstream issues,
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674381
1934
11:28
only one in five doctors said they had
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2273
11:30
any sense of confidence to address those issues,
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2865
11:33
to improve health where it begins.
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681453
1848
11:35
There's this gap between knowing
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1542
11:36
that patients' lives, the context
of where they live and work,
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684843
2429
11:39
matters, and the ability to do something about it
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2808
11:42
in the systems in which we work.
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1777
11:43
This is a huge problem right now,
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2334
11:46
because it leads them to this next question, which is,
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2148
11:48
whose responsibility is it?
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1587
11:49
And that brings me to that third point,
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1709
11:51
that third answer to Veronica's compelling question.
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3274
11:54
Part of the reason that we have this conundrum
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1586
11:56
is because there are not nearly enough upstreamists
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3755
12:00
in the healthcare system.
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708250
2045
12:02
There are not nearly enough of that third friend,
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1900
12:04
that person who is going to find out
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1764
12:05
who or what is throwing those kids in the water.
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713959
2857
12:08
Now, there are many upstreamists,
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1705
12:10
and I've had the privilege of meeting many of them,
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2441
12:12
in Los Angeles and in other parts of the country
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2627
12:15
and around the world,
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723589
1768
12:17
and it's important to note that upstreamists
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725357
2428
12:19
sometimes are doctors, but they need not be.
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727785
2537
12:22
They can be nurses, other clinicians,
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730322
2193
12:24
care managers, social workers.
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732515
2008
12:26
It's not so important what specific degree
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734523
1952
12:28
upstreamists have at the end of their name.
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736475
1799
12:30
What's more important is that they all seem
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738274
1756
12:32
to share the same ability to implement a process
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740030
4425
12:36
that transforms their assistance,
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744455
1789
12:38
transforms the way they practice medicine.
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746244
2346
12:40
That process is a quite simple process.
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1586
12:42
It's one, two and three.
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2373
12:44
First, they sit down and they say,
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752549
1651
12:46
let's identify the clinical problem
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754200
2024
12:48
among a certain set of patients.
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756224
1343
12:49
Let's say, for instance,
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757567
1743
12:51
let's try to help children
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759310
1934
12:53
who are bouncing in and out of the hospital
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761244
1804
12:55
with asthma.
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763048
2082
12:57
After identifying the problem, they
then move on to that second step,
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2511
12:59
and they say, let's identify the root cause.
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767641
2739
13:02
Now, a root cause analysis, in healthcare,
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770380
3791
13:06
usually says, well, let's look at your genes,
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774171
1715
13:07
let's look at how you're behaving.
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775886
2458
13:10
Maybe you're not eating healthy enough.
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778344
2080
13:12
Eat healthier.
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780424
1016
13:13
It's a pretty simplistic
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781440
1395
13:14
approach to root cause analyses.
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782835
1406
13:16
It turns out, it doesn't really work
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784241
1665
13:17
when we just limit ourselves that worldview.
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2464
13:20
The root cause analysis that an upstreamist brings
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788370
2101
13:22
to the table is to say, let's look at the living
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790471
1937
13:24
and the working conditions in your life.
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792408
3352
13:27
Perhaps, for children with asthma,
355
795760
2082
13:29
it's what's happening in their home,
356
797842
1608
13:31
or perhaps they live close to a
freeway with major air pollution
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799450
2936
13:34
that triggers their asthma.
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802386
1824
13:36
And perhaps that's what we should
mobilize our resources to address,
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2620
13:38
because that third element,
that third part of the process,
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2373
13:41
is that next critical part of what upstreamists do.
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809203
2531
13:43
They mobilize the resources to create a solution,
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811734
2239
13:45
both within the clinical system,
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813973
1721
13:47
and then by bringing in people from public health,
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815694
2336
13:50
from other sectors, lawyers,
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818030
1342
13:51
whoever is willing to play ball,
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819372
1947
13:53
let's bring in to create a solution that makes sense,
367
821319
2083
13:55
to take those patients who
actually have clinical problems
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823402
2810
13:58
and address their root causes together
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2183
14:00
by linking them to the resources you need.
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828395
2542
14:02
It's clear to me that there are so many stories
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830937
1777
14:04
of upstreamists who are doing remarkable things.
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832714
2486
14:07
The problem is that there's just not
nearly enough of them out there.
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835200
2660
14:09
By some estimates, we need one upstreamist
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837860
2583
14:12
for every 20 to 30 clinicians
in the healthcare system.
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840443
2946
14:15
In the U.S., for instance, that would mean
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843389
1255
14:16
that we need 25,000 upstreamists
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2096
14:18
by the year 2020.
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846740
3467
14:22
But we only have a few thousand upstreamists
out there right now, by all accounts,
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850207
4110
14:26
and that's why, a few years ago, my colleagues and I
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854317
2553
14:28
said, you know what, we need to train
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856870
1917
14:30
and make more upstreamists.
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858787
1973
14:32
So we decided to start an organization
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860760
1706
14:34
called Health Begins,
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862466
2218
14:36
and Health Begins simply does that:
385
864684
1746
14:38
We train upstreamists.
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866430
960
14:39
And there are a lot of measures
that we use for our success,
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867390
1938
14:41
but the main thing that we're interested in
388
869328
1361
14:42
is making sure that we're changing
389
870689
1912
14:44
the sense of confidence,
390
872601
1539
14:46
that "don't ask, don't tell" metric among clinicians.
391
874140
1905
14:48
We're trying to make sure that clinicians,
392
876045
2299
14:50
and therefore their systems that they work in
393
878344
1940
14:52
have the ability, the confidence
394
880284
2295
14:54
to address the problems in the living
395
882579
2675
14:57
and working conditions in our lives.
396
885254
3007
15:00
We're seeing nearly a tripling
397
888261
1979
15:02
of that confidence in our work.
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890240
1581
15:03
It's remarkable,
399
891821
1303
15:05
but I'll tell you the most compelling part
400
893124
1914
15:07
of what it means to be working
401
895038
1569
15:08
with upstreamists to gather them together.
402
896607
4483
15:13
What is most compelling is that every day,
403
901090
2323
15:15
every week, I hear stories just like Veronica's.
404
903413
3771
15:19
There are stories out there of Veronica
405
907184
2478
15:21
and many more like her,
406
909662
1919
15:23
people who are coming to the healthcare system
407
911581
1881
15:25
and getting a glimpse of what it feels like
408
913462
1378
15:26
to be part of something that works,
409
914840
2560
15:29
a health care system that stops
bouncing you back and forth
410
917400
2473
15:31
but actually improves your health,
411
919873
1821
15:33
listens to you who you are,
412
921694
1127
15:34
addresses the context of your life,
413
922821
2303
15:37
whether you're rich or poor or middle class.
414
925124
4365
15:41
These stories are compelling because
415
929489
1655
15:43
not only do they tell us that we're this close
416
931144
1980
15:45
to getting the healthcare system that we want,
417
933124
2586
15:47
but that there's something
that we can all do to get there.
418
935710
2749
15:50
Doctors and nurses can get better at asking
419
938459
1862
15:52
about the context of patients' lives,
420
940321
1844
15:54
not simply because it's better bedside manner,
421
942165
2511
15:56
but frankly, because it's a better standard of care.
422
944676
3082
15:59
Healthcare systems and payers
423
947758
2342
16:02
can start to bring in public health agencies
424
950100
2790
16:04
and departments and say,
425
952890
1415
16:06
let's look at our data together.
426
954305
1538
16:07
Let's see if we can discover some patterns
in our data about our patients' lives
427
955843
3526
16:11
and see if we can identify an upstream cause,
428
959369
2471
16:13
and then, as importantly, can we align the resources
429
961840
2561
16:16
to be able to address them?
430
964401
2336
16:18
Medical schools, nursing schools,
431
966737
1394
16:20
all sorts of health professional education programs
432
968131
2296
16:22
can help by training the
next generation of upstreamists.
433
970427
3756
16:26
We can also make sure that these schools
434
974183
1755
16:27
certify a backbone of the upstream approach,
435
975938
3228
16:31
and that's the community health worker.
436
979166
2195
16:33
We need many more of them
in the healthcare system
437
981361
1519
16:34
if we're truly going to have it be effective,
438
982880
2353
16:37
to move from a sickcare system
439
985233
1507
16:38
to a healthcare system.
440
986740
1498
16:40
But finally, and perhaps most importantly,
441
988238
2048
16:42
what do we do? What do we do as patients?
442
990286
2559
16:44
We can start by simply going to our doctors
443
992845
2265
16:47
and our nurses, to our clinics,
444
995110
1709
16:48
and asking, "Is there something in where I live
445
996819
2332
16:51
and where I work that I should be aware of?"
446
999151
2343
16:53
Are there barriers to health that I'm just not aware of,
447
1001494
2848
16:56
and more importantly, if there are barriers
448
1004342
1958
16:58
that I'm surfacing, if I'm coming to you
449
1006300
1981
17:00
and I'm saying I think have a problem with
450
1008281
2119
17:02
my apartment or at my workplace
451
1010400
2103
17:04
or I don't have access to transportation,
452
1012503
2196
17:06
or there's a park that's way too far,
453
1014699
1631
17:08
so sorry doctor, I can't take your advice
454
1016330
1860
17:10
to go and jog,
455
1018190
2086
17:12
if those problems exist,
456
1020276
1881
17:14
then doctor, are you willing to listen?
457
1022157
3296
17:17
And what can we do together
458
1025453
1413
17:18
to improve my health where it begins?
459
1026866
2570
17:21
If we're all able to do this work,
460
1029436
2444
17:23
doctors and healthcare systems,
461
1031880
1539
17:25
payers, and all of us together,
462
1033419
2080
17:27
we'll realize something about health.
463
1035499
2194
17:29
Health is not just a personal
responsibility or phenomenon.
464
1037693
3422
17:33
Health is a common good.
465
1041115
3502
17:36
It comes from our personal investment in knowing
466
1044617
1918
17:38
that our lives matter,
467
1046535
2281
17:40
the context of where we live and where we work,
468
1048816
2128
17:42
eat, and sleep, matter,
469
1050944
1736
17:44
and that what we do for ourselves,
470
1052680
1624
17:46
we also should do for those
471
1054304
2120
17:48
whose living and working conditions
472
1056424
2016
17:50
again, can be hard, if not harsh.
473
1058440
2618
17:53
We can all invest in making sure that we improve
474
1061058
2486
17:55
the allocation of resources upstream,
475
1063544
2250
17:57
but at the same time work together
476
1065794
2183
17:59
and show that we can move healthcare
477
1067977
2733
18:02
upstream.
478
1070710
2037
18:04
We can improve health where it begins.
479
1072747
3073
18:07
Thank you.
480
1075820
2027
18:09
(Applause)
481
1077847
2554

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ABOUT THE SPEAKER
Rishi Manchanda - Physician
Rishi Manchanda is an "upstreamist." A physician and public health innovator, he aims to reinvigorate primary care by teaching doctors to think about—and treat—the social and environmental conditions that often underly sickness.

Why you should listen

For a decade, Rishi Manchanda has worked as a doctor in South Central Los Angeles, treating patients who live and work in harsh conditions. He has worked at the Venice Family Clinic, one of the largest free clinics in the United States. He was the first director of social medicine at the St. John’s Well Child and Family Center in Compton, where he and his team provided high quality primary care to low-income families in the area. Currently, he is the medical director of a veterans’ clinic within the Greater Los Angeles Healthcare System, which he refers to as an “intensive caring unit.” He tells the National Health Corps Services, “The moment when a patient switches from despair to hopefulness is the greatest part of my service.” 

Manchanda is the author of the TED Book The Upstream Doctors, in which he looks at how health begins at home and in the workplace, with the social and environmental factors of our everyday lives. He shows how the future of our healthcare system depends on “upstreamists,” the doctors, nurses and other healthcare practitioners who look for the root cause of illness rather than just treating the symptoms.

Manchanda is the president and founder of Health Begins, a social network that teaches and empowers clinicians to improve health where it begins—in patients’ home and work environments. He also founded RxDemocracy, a nonpartisan coalition created to register voters in healthcare clinics. He serves on the board of the National Physicians Alliance, as well as on the board of Physicians for Social Responsibility in Los Angeles.

More profile about the speaker
Rishi Manchanda | Speaker | TED.com