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Upstream: talking differently about health


Social factors play a significant role in determining whether we will be healthy or ill. Our health care is but one element of what makes the biggest difference in health outcomes. This has been understood for centuries, and empirically validated in recent decades with study after study demonstrating health inequalities between wealthy and disadvantaged populations. 

Yet political conversations about health still tend to fall into familiar traps. When we talk about health we return by reflex to doctors and nurses, hospitals and pharmacies. And when we talk about politics — the field of endeavour with the greatest impact on what determines health outcomes — a narrow and economistic outlook seems to trump any attempts to address those social determinants.

Our ability to realize what government is truly for, to improve the lives of people, is hampered by the terms of discussion. Whatever brilliant ideas may come forward to improve lives and health, whatever arguments may be brought forward, they are quickly dismissed if they counter the current frame.

To imagine a different approach, it’s helpful to start with a classic public health parable:

Imagine you’re standing on the edge of a river. Suddenly a flailing, drowning child comes floating by. Without thinking, you dive in, grab the child, and swim to shore. Before you can recover another child comes floating by. You dive in and rescue her as well.

Then another child drifts into sight. . . and another. . .  and another.  You call for help, and people take turns fishing out child after child. Hopefully before too long some wise person will ask: Who keeps chucking these kids in the river? And they’ll head upstream to find out.

Every time we have to clean up an environmental disaster, every time a young person winds up in jail, every time people have to take medicines to make up for the fact that they couldn’t afford good food, we’re suffering from the results of downstream thinking.

Thinking upstream means making smarter decisions  based on long-term thinking­  about what kind of country we want. What better goal than creating the conditions for all people to enjoy true health — complete physical, mental, and social well-being? And what better measure of its success than the health of those people?

First, we have to see beyond health care to what really makes us ill or well – income and its distribution, education, employment, social supports, housing, nutrition, and the wider environment  what are known as the social determinants of health. Examining our decisions through the lens of optimal health allows us to focus our efforts on what makes the biggest difference in our wellbeing.

This also allows us to stop seeing investment in people as a cost. When we take into account the economic and social benefits of a healthy, educated population, we see that by doing nothing to address the factors that make people sick, we ensure that more and more kids will come down the river, and that many of them will drown.

 A new national organization launching this month seeks to bring forward a new way of talking about politics in Canada. Upstream is a movement intent on changing the current conversation. It aims to make the mainstream look upstream, helping citizens to demand a healthy society, and to understand the best ways to get there.

 Upstream seeks to propagate a new frame, one that focuses in on the decisions that will make the most impact on the quality of our lives. By gathering the best evidence available, academics and advocates will promote decisions made on the basis of practicality rather than ideology. Using storytelling through multiple forms of media, Upstream will help to bridge the gap between knowledge and practice.

By connecting individuals and partner organization through common language and goals, Upstream will help to create public demand for policies and actions consistent with the new frame, and ultimately mobilize citizens and our government to build a truly healthy society.




Ryan Meili is a Saskatoon-based family doctor and health equity advocate. He is currently the head of the Division of Social Accountability at the University of Saskatchewan's College of Medicine as well as a Broadbent Fellow.

Follow Upstream on Twitter @UpstreamAction.