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  • Naoimh McMahon

Why the 'upstream-downstream' metaphor doesn't always achieve what it's supposed to

Updated: Jun 29

In my previous post, I described how the 'upstream-downstream' story is used in a very particular and technical way by people writing about the problem of social inequalities in health*. Some of the arguments about what it means to work 'upstream' go well beyond general prevention, and involve quite complex and indeed political actions.


This caused me to wonder whether the story could actually stimulate these insights and perspectives amongst people who, like myself, were less familiar with where it came from and how it's used in academic writing. This blog post is based on findings from a series of interviews that I carried out with people involved in a health research collaboration. During the interviews, I asked people what they felt the 'upstream-downstream' story meant for taking action to reduce social inequalities in health. The published article is now freely available in Critical Public Health [1].


The value of metaphor


Like all good metaphors, the 'upstream-downstream' story works by encouraging us to 'understand one kind of thing or experience in terms of another' [2]. Metaphors are absolutely everywhere (e.g. informal conversation, news headlines, political speeches), and they are especially useful when we are trying to understand things that we cannot directly see or experience.

Metaphors are also an extremely effective way of framing problems or issues. Like a window, they crop our view, and they highlight some aspects or characteristics of a problem, while hiding others [3]. As a result, the metaphors that we use have very real implications for how we understand problems, their underlying causes, what needs to be done, and who is responsible. Examples arising throughout the pandemic have illustrated this very clearly. Indeed, a very different sense of urgency arises when the spread of the virus is framed as a 'wave' (which may retreat of its own accord), in contrast to a 'forest fire' (which will continue unabated for as long as there is fuel to burn) [4].


To my mind, when people use the 'upstream-downstream' story to discuss health inequalities, what they are essentially wanting to do is to reframe the problem and to redirect our focus away from its symptoms (e.g. individual behaviour and uptake of healthcare), to more explicitly consider the role played by socioeconomic inequality in driving unequal health outcomes across society.


But does the metaphor achieve what it is supposed to?


During the interviews, I found that the 'upstream-downstream' metaphor worked for people who (i) either already held quite politically-oriented perspectives on social inequalities in health, or (ii) who already had some knowledge of how the story is used in the academic literature. This group were all very critical of 'downstream' behaviour change interventions, and understood working 'upstream' as actions to distribute income, resources, and opportunities more fairly throughout society.


Everybody else that I spoke to however, had to rely solely on the story itself in trying to think through what it might mean to work in an 'upstream' way. For some people, the story prompted a root cause of analysis of specific instances of inequalities that arose in their work. For example, people identified a range of factors which limit access to healthcare services (e.g. transport to appointments, childcare). Consequently, working 'upstream' was said to be about alleviating these barriers for different groups.


Others interpreted the story as I initially had, as being about any type of preventative action which might stop a problem from arising and reduce the need for hospital care (e.g. dietary advice). Often these kinds of actions were felt to contribute to reducing health inequalities because they were targeted at specific 'high-risk' groups or places.


Importantly, for these latter two groups, it wasn't that people were not attuned to the importance of addressing underlying social inequality, but rather that these insights were often not triggered by the 'upstream-downstream' story itself.


What does this mean and why does this matter?


All of the perspectives described above are entirely valid ways of interpreting the 'upstream-downstream' story. However, the fact that it can be interpreted in such different ways suggests that, especially for people less familiar with its technical meaning and use, the story doesn't work to reframe to the problem in the ways that academics and experts might hope. Rather, this simple anecdote is easily applied to any version of problem which people have in mind and the actions which they are already taking to reduce inequalities.


This is important because it is yet another example of how a concept or idea, which is designed to be a quite radical, challenging, and ambitious call for collective action, is easily transformed to fit with what people are already doing. It also clearly illustrates the problems that can arise when a metaphor, which has come to be used as a technical term with a very specific meaning, is opened-up for interpretation by wider audiences [5].


I really am a big fan of the 'upstream-downstream' story and its underpinning message. However, I also feel that there is a need to move beyond relying on obscure metaphors and shorthand to communicate our points, and be much more explicit and specific about exactly what actions need to be taken, by who, and how to address the underlying causes of social inequalities in health.


This blog post is based upon independent research funded by the National Institute for Health and Care Research Applied Research Collaboration North West Coast (NIHR ARC NWC). I’m currently funded by a NIHR School for Public Health Research Postdoctoral Launching Fellowship. The views expressed are mine alone and are not necessarily those of the National Institute for Health and Care Research or the Department of Health and Social Care.


*I use the expressions 'social inequalities in health' and 'health inequalities' interchangeably in this post to refer to the persistent differences in health outcomes that we see across socioeconomic groups in society. Those who are the most advantaged live longer lives in better health, with life expectancy and years spent in good health reducing as you move through the social scale towards groups who are less advantaged.


[1] McMahon, N. E. (2021). Working ‘upstream’ to reduce social inequalities in health: A qualitative study of how actors of an applied health research collaboration interpret the metaphor. Crit Public Health. Online ahead of print. https://doi.org/10.1080/09581596.2021.1931663

[2] Lakoff G, Johnson M. (2008). Metaphors we live by. Chicago: University of Chicago Press.

[3] Entman R. M. (1993). Framing: Toward clarification of a fractured paradigm. J Commun, 43(4), 51-58.

[4] Semino, E. COVID-19: A forest fire rather than a wave? https://eprints.lancs.ac.uk/id/eprint/151450/1/Semino_METODE_piece_Rev_final.pdf

[5] Semino, E. (2008). Metaphor in discourse. Cambridge: University Press Cambridge.









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