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Before the Bedside

A conversation on the upstream factors of illness.

A growing trend in health care starts by looking upstream at root causes of a patient’s health problems and addressing issues before they cause illness, rather than simply examining the “downstream” symptoms. Upstream teams come from every part of a community— education, law enforcement, business, transportation, local government, and neighborhood coalitions and take on initiatives such as evaluating public policies that affect our health, funding research into societal causes of disease, and sponsoring projects aimed at improving the health of the entire population. Recently, Penn Nursing got on the phone with three champions of upstream health—Calvin Bland, Risa Lavizzo-Mourey, and Bob Atkins—for a far-reaching conversation. What follows is a condensed version.

Penn Nursing: What are the goals of upstream health care initiatives?

Lavizzo-Mourey: The idea is to understand and address the complex factors that can enhance someone’s ability to stay healthy or make it difficult for them to get and stay healthy. The factors are often ones that people who have trained in health care as opposed to public health or population health don’t include in their worldview.

Atkins: We’re trying to bring in players from transportation and housing and school systems. Upstream has to have other voices, all these sectors at the table. Law enforcement. School nurses… Central to this work is the question of health equity and how to increase opportunity for all in our society. That’s why we’re going upstream. That’s where we increase the opportunity. That is what it means to live in a free and just society.

Bland: If you look at any sector of our society—political, social, economic, or religious—you will find things that impact the ability of anyone to lead a healthy and productive life.

Lavizzo-Mourey: Often we don’t see a role for business. But individuals spend a good deal of their time at work and that influences their daily choices and activities.

PN: What are some examples of upstream health initiatives leading to positive outcomes?

Bland: Can I give you a historic one? In the early 1900s, children died from infant pneumonia diarrhea complex. Why did so many children die and why did it get better by the ’30s and ’40s? Upstream. Better sanitation, better water, and better housing reduced the number of hospital beds needed for children and made pediatrics pretty much an ambulatory specialty.

Lavizzo-Mourey: Kids with asthma often end up in the emergency room or hospitalized when they are exposed to things that trigger asthma: mold, noxious chemicals, second-hand smoke. If you address the environment where a child lives and goes to school by eliminating mold and second-hand smoke, you can avoid the use of the Emergency Room, loss of school days, and lost days at work by going to the root cause.

Atkins: In 2015 and 2016, we funded twenty communities across New Jersey—we gave them four-year grants of two hundred thousand dollars each to operationalize upstream health. Each was tasked with bringing more voices and sectors to the table…Every community was different, they were working from the bottom up—each one saying this is what we want to do in Asbury Park or in Camden or Trenton. In Cape May County they brought in a cross-sector team led by the police chief, the school superintendent, the Chamber of Commerce, and somebody from behavioral health. They decided to focus on adverse childhood experiences. How did it affect the business community, law enforcement, schools? We didn’t tell them what they were going to do. We said, “First work and plan and bring different sectors in” and then they focused on housing and childhood lead and different health care challenges.

PN: What’s next in upstream health care?

Lavizzo-Mourey: First, I think that it’s going to be culture change…getting upstream to be part of our everyday thinking. The second is making sure we really do see the unit of analysis as being small enough to make a difference. People being committed to their neighborhood, to their small region—I’ve been very impressed by that. People routinely talking about children in the community as “our children.” They’re willing to innovate and build public schools and invest as opposed to saying, “It’s your kids and my kids.”

Atkins: The unit of analysis has to be the right size as Risa said. But I think we also have to put data tools in the hands of community leaders. If we are going to engage school leaders and police forces we have to give them the tools for policies, systems, and environmental change.

Bland: You have to put the right people together. You need the right people to embrace ideas, the right influence leaders to seek change. I’ve seen progressive and not so progressive hospital leaders. The progressive ones were asking questions other than “who is in my beds?” Look at the influence they have, bring those influence leaders into the tent and get them to buy in.


Bob Atkins PHD RN FAAN graduated from Penn Nursing with his BSN in 1995 and is now director of New Jersey Health Initiatives, a statewide grant-making program of the Robert Wood Johnson Foundation, and an Associate Professor at Rutgers University with a joint appointment in Nursing and Childhood Studies.

Calvin Bland MS, a Wharton grad, retired as Chief of Staff and Special Advisor to the Robert Wood Johnson Foundation’s (RWJF) President in 2008 and is a past President & CEO at St. Christopher’s Hospital for Children. He is an overseer at Penn’s SP2 and a visiting research professor at Rutgers. Penn Nursing is home to one of three Calvin Bland Fellowships endowed by RWJF and named in honor of his retirement from the Foundation.

Risa Lavizzo-Mourey MD MBA is the Penn Integrates Knowledge University Professor of Population Health and Health Equity at the University of Pennsylvania, with joint appointments in Penn Nursing, the Perelman School of Medicine, and the Wharton School. She is the president emerita and former CEO of the Robert Wood Johnson Foundation and earned her MD from Harvard Medical School and her MBA from the Wharton School.