U Magazine
U Magazine
UCLA Health
David Geffen School of Medicine

Reflection from an “Upstreamist” Doctor

  Dr. Rishi Manchanda
  Dr. Rishi Manchanda shares a bold idea for healthcare professionals in his TED Talk.
Photo: Courtesy of Ryan Lash/TED

Rishi Manchanda, MD (RES ’07), MPH, is president and founder of HealthBegins, a social enterprise that provides innovative training, technology and consultancy services to healthcare professionals and community partners to improve care and the social determinants of health. A public-health pacesetter with real-world expertise in improving care-delivery models for vulnerable communities, Dr. Manchanda focuses on improving primary care, the social and environmental conditions that make people sick and health and human rights. In 2008, he started RxDemocracy, a nonpartisan coalition of healthcare and civil-society groups that registered more than 26,000 voters in doctors’ offices and hospitals. In The Upstream Doctors (TED Books, 2013), he introduced a new model of the healthcare workforce that includes clinical “upstreamists” and urges patients and providers to focus on the “causes of the causes” of public-health challenges. Dr. Manchanda is a dual-board-certified internist and pediatrician and was the first graduate of the UCLA Combined Internal Medicine and Pediatrics Residency Program. He leads a program for homeless veterans in Los Angeles, and he was selected as a fellow in the California Healthcare Foundation’s Health Care Leadership Program. In 2014, Dr. Manchanda was recognized in The Atlantic magazine as one of 20 leading healthcare innovators in America.

We all think we know what good medicine looks like: smart doctors, stethoscopes, imaging machines, high-tech tests and the best prescriptions and procedures money can buy. But that picture is vastly incomplete, perhaps fatally so. Our health may depend even more on our social and environmental settings than it does on our most cutting-edge medical care. The future of our health, and our healthcare system, depends on growing and supporting a new generation of healthcare practitioners who look upstream for the sources of our problems, rather than simply going for quick-hit symptomatic relief. These upstreamists, as I call them, are doctors and nurses on the frontlines of medicine who see that health, like sickness, is more than a chemical equation that can be balanced with pills and procedures administered within clinic walls. They see, rather, that health begins in our everyday lives, in the places where we live, work, eat and play.

Upstreamists know that asthma can start in the air around us or in the mold in the walls of our homes. They understand that obesity, diabetes and heart disease partly originate in our busy modern schedules, in the unhealthy food choices available in our stores and even in the way our neighborhoods are designed. They recognize that depression, anxiety and high blood pressure can arise from chronically stressful conditions at work and home and that such conditions can even affect our DNA. And, just as important, these medical innovators understand how to translate this knowledge into meaningful action in their clinics. The upstreamist considers it his/her professional duty not only to prescribe a chemical remedy, but also to tackle sickness at its source. The few upstreamists working in healthcare today — in small practices and community health centers, hospitals and large healthcare systems — struggle daily against a system that wants to push them downstream. In the process of helping their clinics address upstream causes of disease, the upstreamists also help create a higher-value system that can achieve the triple aim of improved outcomes, better quality and lower costs.

Everyone, from patients to fellow doctors to legislators to educators, has a role to play in supporting clinical upstreamists. The United States spends more per capita on healthcare than any other nation; however, the U.S. ranks 37th in health status. If our high-cost sick-care system is to become a high-value healthcare system, the upstreamists will show us the way.

To learn more, visit HealthBegins.


Add a comment

Please note that we are unable to respond to medical questions. For information about health care, or if you need help in choosing a UCLA physician, please contact UCLA Physician Referral Service (PRS) at 1-800-UCLA-MD1 (1-800-825-2631) and ask to speak with a referral nurse. Thank you.