When “Upstream” Public Health Efforts Fall Short

By Nashira Baril

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When I came to public health almost two decades ago, I cut my teeth at a local health department working on what was then referred to as “health disparities.”

The upstream-downstream parable resonated deeply with me. This, and the works of Dr. Camara Jones, Dr. Michael Lu, Dr. Krieger, Surgeon General Dr. David Satcher, and others sent myself and the last generation of public health students and practitioners hiking up the along the river’s edge, committed to address the root causes of poor health.

But, I fear we have gotten comfortable passing off slightly upstream work as equity work.

When we take on single-issue determinant interventions, we lose perspective of the interconnected system of institutions working in concert yielding poor health outcomes. What’s more, lots of SDOH-driven interventions and narratives still posit people — and their otherwise unhealthy behaviors — as the problem. These interventions underscore a dominant ideology that if people (and specifically people of color who persistently have worse health outcomes across a number of indicators) could just access and afford healthier food, if they just had more green space and access to bikes, then they would make healthier choices.

Across public health, we must build a deeper understanding of racism as a system of advantage* — otherwise our health equity efforts are bound to simply remain diversity and inclusion projects.

Diversity is about mixing it up, and inclusion assumes that the existing arrangement is essentially working fine and dictates a practice of accommodation where “diverse” people are given concessions (programs, caucus space, etc) to help them cope within the existing paradigm without changing it.

We must be able to identify when a call for change is about accommodating structurally oppressed people into the existing system.

It can look like focusing on SNAP benefits at farmers markets rather than going further upstream to invoke accountability on the concert of institutions that created food deserts (from big banks to big Ag) and the failures of the public policies and systems that maintain poverty and the need for SNAP benefits (across education, employment, and criminal justice).

  • Socio-economic difference does not explain the racial inequity
  • Inequities are caused by systems, regardless of people’s culture or behavior

If we truly believe that everyone has the fundamental right to the conditions for optimal health, we will face our nation’s history and acknowledge the intentionally designed racial hierarchies and their connection to power. We will begin to leverage our power. And we will commit to healing.

While co-facilitating with a dear friend recently, they said “we have to collectively find our guts.” We mused about what our collective public health practice would look like if we really (and I mean really, really) found our guts on health equity.

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