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Upstream causes and downstream effects

One of the big arguments that people have against any kind of social welfare program is that people should pick themselves up on their own, or that people need to take personal responsibility for their actions. When I was studying for my MPH, a morbidly obese woman sitting next to me told a professor that she didn’t understand why her tax dollars should go toward treatment for heroin addiction. She said that she had nothing to do with getting anyone addicted, and that the addict chose to become addicted. The professor replied to her in a very honest way. He asked her if she had health insurance, to which she said she did. He then asked her if it was okay for the rest of the people in the insurance company’s group to pay for her heart disease and diabetes, especially since they had nothing to do with her being obese.

Of course, she didn’t take it lightly. She didn’t say anything, but she got up and walked out of the class in a huff. I didn’t see her again, but I felt bad for her. The class ended a minute later, after we got our assignment to write about how things and policies located “upstream” affected groups and individuals located “downstream.” For example, how does food policy affect people with diabetes? Or how does drug policy affect young Black men in the inner city? Needless to say, it was an assignment that I was happy to look into.

Those of you who know me personally know that writing assignments can be a bit difficult for me to complete on time because of all the thinking and research that I put into them. I’ve even gotten some assignments with a lower grade because I focused on so many things at once that I don’t get to “the point.” Or I get to several points and end up confusing the heck out of the reader. I do it a lot on this blog as well.

It’s sometimes like an episode of The Simpsons, where I start with one thing and end up on a completely different plane.

We had a speaker come talk to us about one of her books the other day. She is a sociology professor at Hopkins, and she wrote a book about poor women in and around Camden, NJ. The book looked at why women chose to be mothers in light of being poor and disadvantaged. In essence, most women see motherhood as an inevitable goal to shoot for. You can be poor. You can be destitute. But, dammit, you’ll be a mother.

The same applies to a lot of men, by the way. We can be in the most dire of circumstances, but the prospect of being fathers is very appealing. It’s part of the human condition. We see children as entities that will complete us, make us better. And I saw it all the time in my extended family. Plenty of my cousins got pregnant once, twice, three times, or even four times, while struggling to keep themselves fed and clothed.

However, when women are given a chance to succeed, to be educated and well-employed, they seem to wait to get pregnant, or space their pregnancies out. (This is women in general. Your milage may vary.) Indeed, there are plenty of countries where birth rates are below the rate needed for population replacement. Those countries are the ones where women have the most possibilities to be professionals.

That is an example of an “upstream” cause leading to “downstream” effects. Education, better jobs, and better opportunities located upstream incentivize women to wait a little bit longer to be mothers. Furthermore, if they do become mothers, they choose to have less children than similar women with less education, jobs, or opportunities. I saw it in my family as well. Mom went to college in Mexico. She was the only one in her family to do so. She only had three kids. My brother was born when I was seven. My sister was born when I was 21. Only her brother had less children at two. One of her sisters had four. Another one had five. Her oldest brother had six.

I see it in my generation of first cousins, too.

There are other examples of upstream causes with downstream effects. Tobacco taxes, for example, have led to a decrease in deaths associated with smoking. There are also less smokers. And there are more than a few people who have given up smoking because they couldn’t afford the habit. They didn’t change because it was bad for them to smoke, or because smoking causes cancer. Even knowing the bad effects of smoking, it took a stronger “upstream” policy to change their habits.

Not all things upstream have been good to us. Farm subsidies have allowed unhealthy foods to be incredibly cheap. This leads us to this conundrum:

“Some years ago two nutrition experts went grocery shopping. For a dollar, Adam Drewnow­ski and S. E. Specter could purchase 1,200 calories of potato chips or cookies or just 250 calories worth of carrots. It was merely one example of how an unhealthy diet is cheaper than a healthy one. This price difference did not spring into existence by force of any natural laws but largely because of antiquated agricultural policies.”

Someone in a lecture blamed the Americans With Disabilities Act for fostering a culture of laziness in allowing people to take the elevator when they’re perfectly healthy enough to go up or down the stairs. (I get very annoyed when someone uses the elevator to go up or down less than two floors and have no visible disability.)

What about forces going the other way, though? Can downstream forces cause upstream effects? Of course they can. There have been plenty of times when the story or experience of one person leads to a change at a societal level, e.g. changing a law or changing public opinion. Recently, the story of Brittany Maynard — a young woman who had a terminal illness and decided to end her life on her own terms and under the supervision of a physician — has triggered a national and international discussion on euthanasia. Even Pope Francis has weighed in.

Remember John Walsh of “America’s Most Wanted”? The story of Adam, his son, triggered an awareness and action against missing and exploited children. We have Amber Alerts because of the story of Amber Rene Hagerman, a little girl who was abducted and murdered in Texas. And who can forget Rodney King? His videotaped beating made us all come to look differently at how police interact with the public… And how the public interacts with police.

The main takeaway in knowing this is that a lot of what affects us is really not our individual fault. (It could be our collective fault, however.) Yet there are a lot of things we can individually do to make things better for us. The smoker can choose to quit, high taxes or not. The obese person can choose to go for a walk more often, expensive healthy food or not. Men can choose to stay and be fathers. Etcetera. But those things upstream really influence us a lot… To the point that we do some crazy things and don’t do some necessary things.

There lies the biggest obstacle in public health policy.

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René F. Najera, DrPH

I'm a Doctor of Public Health, having studied at the Johns Hopkins University Bloomberg School of Public Health.
All opinions are my own and in no way represent anyone else or any of the organizations for which I work.
About History of Vaccines: I am the editor of the History of Vaccines site, a project of the College of Physicians of Philadelphia. Please read the About page on the site for more information.
About Epidemiological: I am the sole contributor to Epidemiological, my personal blog to discuss all sorts of issues. It also has an About page you should check out.

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