A classic story taught in most introductory public health classes is of the person who finds the body floating in the river, and pulls it out. Then there are more, and he pulls them out. Then more and more and he gets friends. Then so many that the whole town gets involved, developing a highly efficient system for removing bodies from the river, moving them up and out to the graveyard. Until someone says: "Maybe we should go upstream, and try to find out what is causing all these people to die and fall into the river. And maybe do something about it."
"Upstreamers", then, are those who try to find out why the bodies are getting into the river as compared to those who are focused on addressing problems much later; often too late. Upstreamers recognize social determinant and other barriers that can shape outcomes. For the bottom 30 to 40% of Americans, the outcomes can be shaped substantially by various determinants and not by school, teacher, physician, nurse practitioner, etc. Most of the studies regularly promoted in major journals or reports fail to understand social determinants and patient situations.
Our leaders are not listening to the upstreamer family physicians, teachers, public health, military, nurses, and front line public servants. Leaders need to listen to those who have the perspectives that can help to better understand normal Americans and those facing numerous dimensions of challenges. This perspective is often shaped because front liners tend to arise from lower and middle income and upper middle income Americans, rather than the top of the socioeconomic heap. Our top leaders, on the other hand, tend to come more from the exclusive sector, and such upbringing makes it difficult to understand the daily lives of most Americans.
Few want to take responsibility for poor child well being, failures of investment in child development, numerous errors in the production and retention of important health care workforce, health costs that are too high for the outcomes, and other broken designs such as school funding mechanisms. It is easier to blame teachers or physicians rather than to make the investments that can make a difference. It is hard to see how these increasing costs and distractions prevent the investments that we need to make in our children – and our future.
How Do Declining Opportunities for Most Americans Shape Lack of Health Access?
Populations vary in higher education and medical school admission. In the lower income segments, few arise for admission at all. Carnevaleand the Century Foundation have demonstrated that only 3% from the bottom quartile were found in the top 146 colleges – the same ones that feed the same types of students to medical schools. About 74% arose from the top income quartile. In the US middle income populations are disappearing, groups that used to be able to access higher education and they also had reasonable FM probability and distribution probability. The highest income segments are lowest FM probability. For example, at the University of Nebraska Medical School, those whose hometown is Omaha and Lincoln and other metro areas have 2% family medicine while those from the rest of the state have 15 - 30% FM choice (4 years of data). Out of state and foreign born components have been increasing and are typically highest income, most urban, children of professionals.
Asian Indian choice of FM was 2% for the 1990s - the population segment most representative of highest income, most urban, children of professionals in census and in AAMC data. All such populations are 3 - 10 times more likely to gain medical school admission in the US compared to the average. Advantages of child well being from the start of life are evident.
It is not about artificial markers of race or ethnicity - it is about highest income, most urban, highest property value, and other characteristics associated with advantage (or concentrations). Those more normal and representative are falling behind of all races and ethnicities. The same is true in studies of college students. Asian and white populations are populations of advantage and as Barr demonstrated at Stanford, for students who planned to go to medical school when they were freshmen, these students of advantage had 100 – 110% actually apply to medical school, while the rate for underrepresented minorities, even in a select school such as Stanford, was only 50% remaining to apply for medical school. Advantage involves concentrations or combinations of concentrations as compared to normal. Those left behind are no small segment of the United States. Most Americans do not have the concentrations or combinations of concentrations needed for better opportunity, better cost of living, better health care quality, or easy health access.
Recovering Health Care Cost, Quality, and Access
The states doing best in health care quality consistently have the best child well being, the best markers of middle class, and the least divisions between rich and poor. Health care quality, access, and to some degree costs are related to child well being as expressed birth to admission in a student or as expressed birth until health care encounter in a patient. Downstream focus, and ever more dollars invested at the high school or college downstream level will not help. Research that attempts to claim better quality without changing Upstream tends to represent distractions from real improvements.
We cannot do better as a nation with so many left behind from the earliest ages by design.
Health professionals such as family physicians can do Upstream work at the community level.
We need similar professionals working entire careers like we do to improve child development.
We need primary care and public health nurses that were trained specifically for primary care and public health - and who remain in such careers.
How we invest in our children and work locally in teams will determine our future.
 Rabinowitz HK, Diamond JJ, Markham FW, Hazelwood CE. ”A program to increase the number of family physicians in rural and underserved areas: impact after 22 years.” JAMA. 1999 Jan 20;281(3):255-60.