What do people mean when they talk about 'upstream' action to reduce social inequalities in health?
The 'upstream-downstream' story
I am standing by the shore of a swiftly flowing river and I hear the cry of a drowning man. I jump into the river, put my arms around him, pull him to shore and start artificial respiration, and just when he begins to breath, I hear another cry for help. So, I jump back into the river, reach this person and pull them to shore. And again the same, just as they begin to breathe, another cry for help. So back into the river I go…and on and on the sequence goes without end. And I am so busy pulling people to shore that I have no time to see who the hell is upstream pushing them all in. 
I first heard this story when I trained as a physiotherapist and was really taken by how well it captured the experiences of so many people working in healthcare. The story also brilliantly demonstrates the insanity of dedicating so much time, energy, and resources to heroically picking up the pieces when things go wrong, instead of more fully understanding the root causes of problems and investing in prevention .
This story is very often used by people writing about social inequalities in health* and although I had understood it to be about preventative action more generally, I quickly realised that these authors were using the story in a very different way. This prompted me to pull together a summary of how the story is used in the health inequalities literature, and this post reflects findings published in an article now freely available from the Journal of Public Health .
1. 'Upstream' action is not just any old prevention
It was my understanding that 'downstream' actions were those which involved treatment and cure after a problem had arisen, so that any actions which came before this point would count as 'upstream'. But within the health inequalities literature, these terms are actually used in a very specific, and even technical way.
Most often, they are used to distinguish between 'downstream' causes of health inequalities (e.g. individual lifestyle behaviours and uptake of healthcare), which are seen to be symptomatic of more ‘upstream’ causes (e.g. income, education, living and working conditions).
Authors who use these terms are generally quite critical of 'downstream' actions which target individual behaviour because they are seen to put too much emphasis on individual responsibility and often fail to consider or address the wider reasons why behaviour change might be difficult for people.
When authors use the 'upstream-downstream' distinction to discuss social inequalities in health, what they are effectively doing is challenging us all to think differently about this problem, to move beyond the idea that it is simply an issue of individual choice and behaviour, and to consider other reasons why good and poor health outcomes so often arise in the same pattern across different groups and places in our society.
2. 'Upstream' actions depend on what version of the problem you're interested in
It was interesting to see that while people put forward the same criticisms about acting on 'downstream' causes, their perspectives about what actually counted as 'upstream' depended on how they were thinking about health inequalities, and what aspect of the problem they were specifically wanting to address.
For example, when the focus was on how environments shape health behaviours (e.g. food on our shelves, green space), 'upstream' policies were those which, instead of encouraging individuals to make a change, actually change the environment itself (e.g. by making 'unhealthy' products more expensive; requiring manufacturers to change their ingredients).
This was quite different to authors who focused on how people's health is impacted by the financial resources available to them, and also the conditions in which they live and work (Covid-19 couldn't have demonstrated this more clearly for us). For these authors, 'upstream' policies were those which help to make sure that income and wealth are shared more fairly through society e.g. through progressive taxation, increases in the minimum wage, investment in education and training.
Taking a slightly different angle again were authors who highlighted how harmful social norms can limit how much control different groups have over their own lives and health (e.g. norms around gender roles). For these authors, ‘upstream’ actions were those which were attentive to how people's relationships to others can impact on their health, and which try to bring about positive changes in what are socially acceptable beliefs, practices, and behaviours.
3. 'Upstream' action is not just about what is needed, but also how to make it happen
Finally, it was clear that use of the 'upstream-downstream' distinction has changed and evolved over time. It used to be the case that these terms were primarily used to categorise causes and policies (as described above). But progress in reducing inequalities in health has been slow at best , and this seems to have prompted a greater concern with how to make change happen.
Authors suggested that to effectively work 'upstream' and advocate for change, we all need to become much more politically literate, as real change will only come about when people concerned to see reduced health inequalities have a much better appreciation of how politics works. Others described the need for health and public health professionals to work more effectively with grassroots movements who can lead on campaigns for 'upstream' change (e.g. by providing supporting data and evidence).
Reflecting on how change happens within institutions (e.g. government), some authors described that it is not enough to establish new teams, processes, or infrastructure. Rather what is needed is a change in the deepest held institutional beliefs and ideologies as these ultimately shape how problems are approached and addressed. Lastly, I noticed that the 'upstream-downstream' metaphor was used to challenge academics to stop contributing to the overproduction of evidence for 'downstream' actions (which are distinctly easier to research and evaluate), and to broaden their research toolkit to produce more, and better, evidence for actions that can address the underlying causes of social inequalities in health.
All of that from a simple story?
It's an impressive display of arguments communicated using what appears to be a pretty simple and straightforward metaphor. But thinking back to the story presented at the outset of the blog, and indeed my initial understanding, it raises the question of how likely it is that people will be able to glean these insights or draw these conclusions when they hear or read about the need to work 'upstream'? Considering the profound impacts of social inequality on health, especially during the ongoing pandemic, I'm not sure we can afford to be vague or obscure in communicating what the evidence suggests is needed. So, can this metaphor work for people who perhaps aren't as familiar with health inequalities or the underpinning literature? I'll have a blog post on that shortly.
This blog post is based upon independent research funded by the National Institute for Health 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 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.
 Adapted from McKinlay (1979) A Case for Refocusing Upstream
 See here for a great image of the story
 McMahon NE. (2021). Framing action to reduce health inequalities: what is argued for through use of the ‘upstream-downstream’ metaphor? J Public Health. Online ahead of print. https://doi.org/10.1093/pubmed/fdab/157
 Marmot, M., Allen, J., Boyce, T., Goldblatt, P., & Morrison, J. (2020). Health Equity in England: The Marmot Review 10 Years On. London Institute of Health Equity.