Are You Upstream or Downstream?

by | Feb 3, 2023 | Blog, Featured, Integrative Medicine | 0 comments

The metaphor that describes the need for an upstream approach to healthcare exemplifies why any functional medicine doctor chooses his/her field. Coined by Irving Zola and made popular in McKinlay’s defining paper, “A case for refocusing upstream: The political economy of illness”, this metaphor illustrates the different approaches to health and disease management, while demonstrating both the need and unfortunate lack of “upstreamists” in conventional medicine.

Imagine three friends make their way to a fast-flowing river that leads to a powerful waterfall. They suddenly hear multiple cries for help. As they race closer to the river, they see many people have fallen in and are at risk of going over the waterfall. One friend immediately jumps in and starts to rescue those that are in imminent danger of drowning. The other friend builds a raft to grab more people. As these two friends frantically try to rescue people, they notice their third friend swimming upstream. “What are you doing, we need help down here?” And the third friend replies, “I’m going to find out why people are falling into the river and help there”. Adapted from Rishi Manchanda’s Ted Talk: “What makes us get sick? Look upstream.”

In this metaphor, the first friend represents paramedics, ER doctors and nurses that help in cases of emergency and urgent care. The second friend represents the family physician, building a raft to support and manage a patient’s chronic condition—diabetes, high blood pressure, chronic pain, etc. The third friend is an “upstreamist”, the person that asks how and why a patient has developed chronic disease and identifies the factors at home, work and play that are contributing.

At Markham Integrative Medicine, we are the upstreamists. We focus on the factors that are too often ignored—environmental exposures, diet and nutrition, stress and emotional wellbeing. Patients see upstreamists when they have used the downstream approach to no avail.

Environmental Exposures

This is the most overlooked contributor of health in conventional medicine today. Exposures to pesticides, heavy metals, and other toxins have been linked with mental health disorders, cancer, infertility and more. But MDs don’t regularly ask “Do you have mold in your house?” or “How old are your home’s water pipes?” By asking the right questions and using specialty testing, upstreamists determine when environmental exposures are having a negative impact on your health.


We know that a healthy diet is important. And if you are overweight, have diabetes, arthritis or heart disease, your family doc has probably told you to eat a healthier diet. He may have gone so far as to show you Canada’s Food Guide (not that I’m saying its healthy), but then the conversation stopped and he left you to your own devices. With little information, you may have circled around Dr. Google, searching for the right diet only to surface confused and overwhelmed. Upstreamists thoroughly examine your diet and based on your current health and goals, provide you with clear guidelines. The result is a healthy food plan that is tailored to you and your health needs.


Another major factor of health is stress, which contributes to heart disease, weight gain, mental health disorders and more. But how is stress affecting you specifically and are your coping mechanisms helpful or detrimental? These are the questions that upstreamists answer.

Emotional Wellbeing

When it comes to mental health, conventional medicine exhibits the classical downstream approach. If a patient is depressed or anxious, he is given a medication that prevents the breakdown of his “feel-good” brain chemicals to have a stabilizing effect on his mood. But this approach is not always effective. Why? Because it overlooks the vitamins, minerals and protein needed to produce the brain chemicals. And it doesn’t address the stress and poor eating habits, which deplete the body of these nutrients. An upstreamist approach addresses mental health holistically, providing appropriate nutrients, managing stress and incorporating counseling.

This discussion identifies a broader issue: disease-centered vs. health-centered care. Disease-centered care is the downstream approach. This approach waits until you are sick; until you cannot ignore your symptoms; and until your quality of life is diminished—at which point you take medication or undergo surgery. Health-centered care is the upstreamist approach. By focusing on the factors that lead to disease, health-centred care focuses on prevention and optimizing one’s health, instead of mitigating disease. Which type of care do you want to receive?

Learn more about working with Dr. Gannage