When “Upstream” Public Health Efforts Fall Short

By Nashira Baril

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.

We set up camp slightly upstream, by deepening our understanding of the role of place and moving beyond a myopic focus on individual behavior change. For example, rather than just telling people to eat healthy, we advocated for farmers markets to accept SNAP benefits. We put our sweat and dollars into increasing the availability of fresh foods in corner stores and expanding greenways. Our training on social determinants of health (SDOH) oriented us to advocate for bike share programs, complete streets, even high-speed rail in neighborhoods that have historically been redlined from transportation investment.

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.

Now, do not get me wrong, these interventions are important to the public’s health — but they do not demand systemic change. In this way, health equity work “services” communities of color, while staying relatively apolitical and keeping the status quo intact, or worse, exacerbating inequity.

For example, when we increase access to transportation without a structural lens, private and capital investments follow, rents skyrocket, and the community that the healthy transit plan was intended to benefit is ultimately displaced. This is the case in my neighborhood, where one part of a multi-pronged organizing effort included adding stations to the commuter rail line that bisected Boston’s neighborhoods of color, but did not stop on its way from the suburbs to downtown. Part of the effort was successful, resulting in new stations and affording Dorchester residents quick access to downtown Boston. But tandem efforts to stabilize housing didn’t get the same traction. Now, the previously “affordable” triple decker rentals along the rail are being sold as condos in the $400Ks and advertised with “quick access to Boston’s city center.” When efforts to “green” poor and polluted neighborhoods lead to displacement it’s called “green gentrification” and it’s happening in Brooklyn and many other communities of color.

Some health departments have come to explicitly name racism as a root cause of the inequitable distribution of social and environmental factors that influence health, but we need to go beyond that.

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).

The World Health Organization warns that “conflating the social determinants of health and the social processes that shape these determinants’ unequal distribution can seriously mislead policy.” Simply accommodating people in systems that were never designed for their survival is inherently inequitable. We must understand how things got this way and explicitly address the systemic imbalance of power and advantage in our approaches to health equity.

At HIP we have found the Racial Equity Institute’s Groundwater Approach a very useful allegory to illustrate that our racially structured society is what causes racial inequity. The analysis is based on 3 observations:

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

They also point out that the challenges of working on the structural level are exacerbated by the myriad of different ways we talk about inequity. (Just ask your colleagues in education, criminal justice, or business what they call persistent racial differences in their field and you’ll hear different terms for the same structural inequity.)

Downstream, upstream, groundwater? I don’t believe this is merely a case of arguing semantics. As a public health community, we don’t have a shared analysis, in spite of our widely shared definition(s) of health equity.

My former boss John Auerbach just wrote a piece with Brian Castrucci about this in Health Affairs. They say, “Social needs interventions create a middle stream. They are further upstream than medical interventions, but not yet far enough. Social needs are the downstream manifestations of the impact of the social determinants of health on the community. Improvements in our nation’s health can be achieved only when we have the commitment to move even further upstream to change the community conditions that make people sick.”

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.

What if we focused our energy on justice? Or liberation? Perhaps then, we wouldn’t use “health equity” as proxy for governmental programs simply because they operate in Black and Brown communities, or for policies designed to diversify an organization, or for practices that merely accommodate people in broken systems. These do nothing to redistribute power — providing the illusion of investment, while maintaining structural inequity.

Whether it’s going further upstream or deep in the groundwater, we must challenge ourselves to build authentic and deep relationships and employ radical strategies that shift our “service” mentality so we can imagine world where we all get free. The health of my children and their children requires that we work towards liberation.

*Wellman, D. (1993). Portraits of White Racism. Cambridge: Cambridge University Press. doi:10.1017/CBO9780511625480


Nashira Baril is a Project Director at Human Impact Partners. Nashira designs and coordinates Health Equity Awakened, HIP’s national capacity building leadership institute for individuals working on health equity in local health departments.

📌 Did you know? Human Impact Partners provides health equity capacity building to local and state health departments. Contact us to learn more about our offerings at info[at]humanimpact.org.