Upstream/Downstream

Story of Moving Upstream: “I am standing by the shore of a swiftly flowing river and hear the cry of a drowning man. I jump into the cold waters. I fight against the strong current and force my way to the struggling man. I hold on hard and gradually pull him to shore. I lay him out on the bank and revive him with artificial respiration. Just when he begins to breathe, I hear another cry for help. I jump into the cold waters. I fight against the strong current, and swim forcefully to the struggling woman. I grab hold and gradually pull her to shore. I lift her out onto the bank beside the man and work to revive her with artificial respiration. Just when she begins to breathe, I hear another cry for help. I jump into the cold waters. Fighting again against the strong current, I force my way to the struggling man. I am getting tired, so with great effort I eventually pull him to shore. I lay him out on the bank and try to revive him with artificial respiration. Just when he begins to breathe, I hear another cry for help. Near exhaustion, it occurs to me that I'm so busy jumping in, pulling them to shore, applying artificial respiration that I have no time to see who is upstream pushing them all in....” (Adapted from a story told by Irving Zola as cited in McKinlay, John B. "A case for refocusing upstream: The political economy of illness." In Conrad and Kern, 2nd edition, 1986, The Sociology of Health and Illness: Critical Perspectives. pp. 484-498.)

This is a classic public health primary prevention story. Our current approach to health care is to treat the symptoms of illness when we need to be focusing on prevention of the illness. We continue to try to "rescue" people with heart disease, diabetes, cancer by giving them medications that are supposed to be medical life preservers all the while people continue to fall in. At what point do we stop trying to rescue people and start preventing people from "falling in"?

We should start to assign a different duty to the rescuer and furnish her with some interesting "supplies." Here's our twist: When the rescuer arrives upstream she finds it is evident who is doing the pushing. She addresses the pusher, finds out why he is pushing, and does what she can to stop him from pushing anymore people into the river.

Here is another twist on the same story: "Suppose you are standing next to a river, and you see someone drowning as she floats downstream. You jump into the river and pull her ashore. As soon as you've done that, you see another person in trouble, again floating downstream, and you rescue him as well. Every time you've saved one person, you see another, and another. After you've dragged another drowning body out of the river, you're thoroughly exhausted and you know you don't have the energy to save one more person, so instead you decide you must go upstream to find out what is causing these people to end up in the river. You want to address this problem at its source. You get upstream, and see a bridge. Upon careful inspection, you find that there is a well-concealed, yet sizable hole in this bridge that is causing people to fall in. What do you do? You do what makes the most sense - you work to repair the bridge. Primary prevention means "going upstream" and repairing the bridge before more people fall through this hole. Too often we just focus on the tangible aftermath of a problem. We just keep pulling people out of the river - we set up systems to support people who are suffers of illness. While these systems of support are crucial, we also need to cultivate complementary systems that get to the core of the problem, stopping it from ever happening in the first place. We need to become proactive, go upstream to that bridge, study it, determine what resources we need to repair it, and start doing the long and hard work of primary prevention. It means examining and changing individual attitudes that lead to patterns of relating that create norms that shape the institutions in our society that allow unhealthy behavior to thrive. Addressing these underlying factors is all the more difficult because they are intertwined with the identity of our society."

The key thing about this version that I've found useful is the metaphor of a "well-concealed, yet sizable hole" in the bridge to represent the factors in our society that help support unhealthy lifestyles and yet seem/are so commonplace. So I guess this version might be more geared toward trying to get those "big picture" factors across to people, whereas other versions of this story - where you go upstream and find someone pushing people in - might work better for exposing factors that are at a more individual level.

I realize there seems to be a common theme to my writing, but there is logic behind it. It is said that people normally do not grasp an idea when they first hear or read it. It is only after repetition that people will begin to grasp the message being sent.

People will continue to do what is easy or familiar even when what is easy or familiar is bad for them. Case in point: You drive the same route to work every day. You are always angry and stressed by the time you get to work because traffic is always backed up. You do this for months and years and never think to find a different route to work. A new route may take a little longer, but has less traffic and, therefore, causes less stress. It takes time to find the new route and become familiar with it. Maybe you have to get up 15-30 minutes earlier to get to work on time. Most times people will not make the change because it is easier to stick with what they know no matter what the cost than to change their routine.

It is the same with changing your lifestyle. My significant other knows that how he eats isn't healthy. He has been taking supplements for years. Yet his reasoning for not changing the way he cooks and eats is that "he doesn't know how." Even when I give suggestions of where easy changes can be made, there is no change. There is no change because it isn't his norm.

People have to stop sticking with what is easy or comfortable even when they know it is bad for them. It is way past time for people to step out of their comfort zone and start fixing their lives. The payoff is so worth it!