The Upstream Doctors, by Rishi Manchanda

. The Upstream Doctors, by Rishi Manchanda

Dr. Rishi Manchanda’s TED Book addresses all of these questions with clarity and vision and humility. His vision is informed by long experience, illuminated by the experience of his patients, and solidly buttressed by a great deal of data. The book’s title is borrowed from a well-known parable. Three friends come upon a terrifying scene: as a broad and swift river approaches a waterfall, they see floundering children being swept by in the current, heading towards the cataract. The three friends do the right thing: they jump in and save the drowning children. But the rescuers’ horror is compounded when more kids keep coming down the river. Finally, one of the three starts swimming away from the struggling children. Over the objections of her fellow Samaritans, panicked as they continue their heroic rescues, she swims upstream “to figure out what or who is throwing these kids in the water.”

It’s not that Manchanda is arguing in these pages that we don’t need to save all those already swept into perilous waters. It’s rather, he argues, that we need to divert some of our attention and resources—perhaps more than a third of them—to addressing the root causes of that peril. In other words, we need our physicians to be technically competent, excellent listeners, and able to understand pathogenesis—especially when sickness is not caused, or caused solely, by a microbe or an accident or a readily identified genetic mutation.

most of these causes are to be found far upstream of the etiologies we are taught to seek in medical school and in teaching hospitals.

Effective care for most illness requires understanding the social conditions of one’s patients.

Any system designed to treat AIDS based solely within the hospital or clinic will fail. 

"In the eyes of most of our colleagues, however, these particular patients were “failing medical therapy” for AIDS, which was revolutionized for some by the advent, about 20 years ago, of effective therapy. But in Dr. Behforouz’s view, medical therapy was failing them. Even though most were and are eligible for such therapy through publicly funded programs, they were not adhering to the treatment nor enjoying ready access to many other social services. Was the primary problem the non-compliant patients, or were their upstream problems, from housing instability to running afoul of the law and the other “synergy of plagues” that ran together in their lives, limiting their ability to comply, keep appointments, fill prescriptions, and all the other things we ask of patients. How much of the problem was due to fractured and inconvenient systems of care? Were the upstream problems really beyond the reach of a coalition of concerned providers?"


For patients with chronic diseases, like AIDS or poorly controlled diabetes or major depression, good hospital care with little community-based care usually adds up to mediocre outcomes.