Category: Social Determinants

Health Benefits of Going Green

House plants have always been a staple of many people interior and exterior design. Our fascination and attraction to greenery is long-ingrained in human history. However, new research is show that there may be serious health benefits to being exposed to greenery. A UCLA study has shown that increasing “greenness” in urban settings can improve mental health.

In addition to this, there are a number of other studies which suggest positive relationships between greenness and a number of disease outcomes, such as obesity, preterm birth outcomes, depression and Alzheimer’s disease. These studies provide interesting and exciting glances into an emerging field, which highlights the importance of greenness and preserving natural landscapes. These things can improve public health, and likewise benefit our natural environment.,_Air.4.aspx





Lack of Diversity in Fashion: impacts on mental health

Today, when one looks through the catalogues and social media accounts of many well-known fashion brands, homogeneity can be expected. When focusing specifically on women’s fashion, there is a major issue of lack of representation in diversity of models. This applies to many fronts: lack of diversity in race, body size, body type, etc. Trans-women and women who don’t conform to gender “norms” are often excluded, and brands rarely depict models with visible health conditions and/or disabilities.

This lack of representation can have seriously negative impacts on the mental health of many people of different ages. Most often, models are skinny, tall, and white. When these are the only women being depicted in the media as desirable – it can weigh heavily on the shoulders of those who do not and cannot conform to these standards.

The good news: the tides seem to be changing. Certain brands have begun to combat these patterns in fashion branding. This is not in an attempt to tear current models down, but rather to lift women of all shapes, sizes, colors and statuses up. Aerie – a women’s clothing and lingerie brand – has taken on the frontline in this battle. In 2014, Aerie launched “AerieReal”, an admirable campaign to promote the beauty of all types of women in an untouched beauty campaign. Brands like Aerie serve as a beacon here and sets a positive example of how to better promote the physical and mental health of their customers.



House made of puzzle pieces with one piece missing

Housing First helps homelessness and saves money

Housing First is catching on across the county with great results. In this model, homeless and housing-unstable individuals are provided with permanent housing before the organization attempts to address other issues like substance use and employment.

The Housing First Model has seven core tenets:
1. There are few if any prerequisites to permanent housing
2. There are few barriers to entry.
3. They allow for rapid entry to housing
4. Supportive services are encouraged but are ultimately voluntary
5. Tenants have full legal rights, responsibilities, and legal protections
6. They include policies, like installment payments for missed rent, that help prevent evictions.
7. This model can be applied in many housing types.

The University of Illinois Hospital started a Housing First modeled program as they a direct connection between housing and health. In November 2015, they committed $250,000 to re-housing their homeless frequent emergency department users. Among the program recipients the hospital has seen a 57% reduction in inpatient stays and a 67% decrease in emergency department utilization since its inception.  This means healthier people and less cost on the already strained medical system.

Though some may find the idea of providing housing without additional stipulations controversial, even our federal government has started endorsing this practice.  On the United States Interagency Council on Homelessness’s website, the first item listed under “solutions” is to deploy a system-wide housing first program. By providing homes without additional barriers, Americans save up to $23,000 per participant compared to the cost of traditional housing programs.

As this model spreads across the country, support it with your votes and actions.  Look for politicians who support this model and want to allocate city funds toward housing first.  Its just one more way we can help our fellow humans.




To Address the Spread of Misinformation, Get Specific

With greater access to information, it’s become increasingly hard to tell fact from fiction. (Source: Paintings (Triptych) by Wang Jianwei 汪建偉)

In the current polarized political climate, it is increasingly necessary to carefully frame the results of health and basic science research. Health researchers need to be aware of the potential misuse and misinterpretation of their research.

Concerningly, white supremacists have brought this problem to a national stage. A recent NY Times article describes the misappropriation of genetic research, used by the far right to lay claims to a biological basis for socially-determined traits like race and intelligence.

Misinformation has been addressed before on Upstream Downstream, but the problem is increasingly relevant. Researchers can pre-empt some of the abuse and distortion of their findings by engaging and expanding on the ethical and social implications of their work.

For example, one or two sentences in the discussion section of a manuscript could rebuff parties that have their own agenda. Situating findings within their broader social contexts, such as the specific upstream causes of health disparities, may mitigate the spread of fake news.

The framing around racial health disparities, for example, could be improved by actually naming racism as the root cause of poor health— instead of ending the conversation by identifying the marginalized groups who suffer from worse outcomes.

Taking the extra step to be explicit in communicating findings around health and science can go a long way.


-Steven Houang

Designer Babies: Questions of Ethics

Imagine a world with no disease. No one gets cancer, birth defects are a thing of the past, and STDs like HIV have been eliminated. At the end of 2018, Chinese scientist He Jiankui announced that we were one step closer to this reality. He had successfully created genetically altered babies, who were, he claimed, resistant to HIV. This announcement threw the scientific community into an uproar. It reignited a decades old debate over the role of eugenics amid our increasing ability to alter—and select—the human genome to create the “perfect” human. Some countries banned all gene-editing in response, pending review. The ethical implications of gene-editing are complex, and we can no longer delay discussing them. These are some of the questions that you should be asking:
1) Does creating “designer babies” increase disadvantages or discrimination within a society? In other words, if we can create the “perfect” human, how are the less than perfect humans affected?
2) When should we allow gene-editing in humans? Gene editing that removes a devastating disease may be acceptable. What about gene editing that determines eye-color or intelligence? Where do we draw the line?
3)What are the population-level implications of gene-editing human embryos?
4) What are the potential benefits of gene-editing in humans? Beyond addressing illness, could gene-editing also be used to change personality traits?
5) Who gets to decide whether gene-editing is permissible? What gives them the authority to do so? Who else deserves a say?
6) What are the appropriate legal measures in favor or against gene editing in humans?
Check out these links for more in-depth discussion of these issues:

Mental Health Issues Rise Alongside Global Temperatures

It’s no secret that the impacts of climate change extend far beyond our surrounding environment. Numerous sources have shown that our changing climate is associated with a variety of health issues: infectious disease, heatstroke, hyperthermia, respiratory problems, and natural disaster-related injury. However, new literature is beginning to dive deeper on these issues, and how they can affect more complicated outcomes, such as mental health.

Recently, a study conducted by MIT’s Nick Obradovich examined how rising temperatures may be responsible for both direct and indirect causes of mental health issues. The report evaluated 2 million randomly-sampled individuals in the U.S. for mental health issues, which included anything falling in the range of stress, anxiety, depression, and other emotional issues. Obradovich roughly defined these issues as “basically means things that are less extreme than hospitalization and suicide but more significant than like grumpiness or day-to-day emotional [agitation]”.

Following this, his team linked these reports with weather data from their respective cities. The team examined how different climate-change weather events (rising temperatures, excessive precipitation, lack of precipitation, extreme temperature changes, and hurricanes) might be associated with the mental health reports for that region. The team found that most of these weather or climate characteristics were linked to a higher likelihood of mental health cases.

Despite this critical new findings, there’s still much to be understood regarding the mechanisms underlying these outcomes. Most of the current hypotheses consider stress a huge mediator. Not only do these events cause stress, but they often disproportionately affect people living in poverty. Researchers are trying to understand these relationships, so that better preventative measures and interventions can be made going forward.


Hurricanes & Our Health

As Hurricane Florence approaches, there are many worries on the minds of those who live in its path. Residents in the South Eastern United States are anxious about the wellbeing of their property, belongings, surrounding environment and loved ones. Along with these concerns, it’s important to be weary of how a destructive hurricane can also have serious implications on medicine and public health. Considering these risks before the onset of the storm could eliminate smaller preventable problems and render larger issues easier to address.

Before the hurricane arrives, it’s advised that any medical prescriptions be refilled and retrieved promptly. Resultant power outages and infrastructural damages may limit a pharmacy’s ability to operate and supply their patients’ needs. If you know you are at risk of power outages, it’s important to stock up on non-perishable foods, water, and anything else necessary for your individual health. Along with this, following proper safety precautions to protect your home from water and wind damage can also prevent a number of storm-related injuries.

In North Carolina, the magnitude of rain expected to come with Hurricane Florence is especially worrisome. Excessive rainfall could cause flooding in farmland which contain animal manure lagoons. Such lagoons could overflow, spreading waste and increasing risk of disease transmission. Additionally, North Carolina is home to a number of dangerous coal-ash ponds. If these sites flood, it could unleash this waste into the surrounding environment. Coal-ash is toxic, and if released from ponds could contaminate people’s public drinking water.




The Continuing HIV Disparity for Black Men

Despite only making up 2% of the U.S. population, men who have sex with men (MSM) account for 52% of the U.S. population of individuals living with HIV, and these rates don’t seem to be decreasing.[1] In 2013, MSM accounted for 65% of new HIV diagnoses.[2] Among MSM, black men are disproportionately at risk of contracting HIV, accounting for 30% of MSM living with HIV and almost 40% of new HIV diagnoses in 2012 though black people only constitute about 13% of the U.S. population.[3] Of these black MSM newly diagnosed, 38% were between the ages of 13 and 24 in 2015.[4] Of black gay and bisexual men living with HIV, only 54% received continuous HIV care.[5]

These statistics illustrate the stark disparity in HIV treatment and prevention for queer black men, especially younger queer black men. According to a 2018 CDC report, black men are not receiving PrEP prescriptions or being provided PrEP at the rate that they should be.[6] Some health professionals will likely attempt to target black MSM, claiming that they are less likely to be aware of PrEP, are more likely to have sex with other black men and are thus more likely to contract HIV because of the higher prevalence rate in black communities, are more likely to participate in riskier sexual behaviors, are less willing to take medications, etc. Many of the reasons for lower PrEP usage among black MSM will likely be attributed to decisions made by black MSM themselves.

However, in 2014, Calebrese et al found, in a nationally representative sample of medical students, that students were less likely to prescribe PrEP to a black man than a white man.[7] A pervasive logic surrounding PrEP, exacerbated by the stereotype of the Truvada Whore, is that people who take PrEP will participate in riskier sex.[8] However, PrEP should be the answer to protecting individuals who are participating in riskier behavior.[9] Ultimately, this logic is backwards and slut-shaming, and it puts black MSM at greater risk because it keeps them from being prescribed PrEP.

We should be looking to medical schools to better prepare their students to provide necessary care to LGBTQ+ people more broadly, but also from this example more specifically to black MSM. We should also be targeting current providers to combat issues of implicit bias, homophobia, and heterosexism that are preventing LGBTQ+ individuals, especially black MSM, from accessing the best possible care.

[1] “MSM Population Profile.” AIDSVu, 9 Mar. 2018, AIDSVu is maintained by faculty and staff at Emory University’s Rollins School of Public Health in partnership with Gilead Sciences, Inc. and the Center for AIDS Research at Emory University (CFAR) with assistance from members of other institutions. Some of the data and statistics presented on the AIDSVu website is provided from other medical and health surveillance institutions, such as the CDC.

[2] Ibid.

[3] Ibid.

[4] Ibid.

[5] “HIV among African American Gay and Bisexual Men.” Centers for Disease Control and Prevention, 14 Feb. 2018,

[6] “HIV prevention pill not reaching most Americans who could benefit – especially people of color.” Centers for Disease Control and Prevention, 6 Mar. 2018,

[7] Calabrese, S. K., Earnshaw, V. A., Underhill, K., Hansen, N. B., & Dovidio, J. F. (2014). The Impact of Patient Race on Clinical Decisions Related to Prescribing HIV Pre-Exposure Prophylaxis (PrEP): Assumptions About Sexual Risk Compensation and Implications for Access. AIDS Behav, 18(2), 226-240. doi:10.1007/s10461-013-0675-x

[8] Calabrese, S. K., & Underhill, K. (2015). How Stigma Surrounding the Use of HIV Preexposure Prophylaxis Undermines Prevention and Pleasure: A Call to Destigmatize “Truvada Whores”. Am J Public Health, 105(10), 1960-1964. doi:10.2105/ajph.2015.302816

[9] Calabrese, S. K., Magnus, M., Mayer, K. H., Krakower, D. S., Eldahan, A. I., Hawkins, L. A. G., . . . Dovidio, J. F. (2017). “Support Your Client at the Space That They’re in”: HIV Pre-Exposure Prophylaxis (PrEP) Prescribers’ Perspectives on PrEP-Related Risk Compensation. AIDS Patient Care STDS, 31(4), 196-204. doi:10.1089/apc.2017.0002

Primary Care Access in Rural Areas

Rural areas of the U.S. face unique barriers to healthcare that must be approached with a systematic framework. One access issue is a lack of primary care practitioners (PCPs) in rural areas: despite existing incentive structures for PCPs to complete residencies in rural areas, there is still a provider shortage, leading to limited access to providers for rural residents. A lack of providers in a given area could manifest itself in fewer appointment slots or longer wait times, for example. Poor access to primary care has been found to be both an effect of poverty and a cause of further health disparities.

A study of barriers to preventative screenings in Appalachia found that “lack of knowledge about prevention and cost” were the primary obstacles, impacting 51% and 36% of participants, respectively. In Graham County, NC, a county in Appalachia that is 100% rural, the local Department of Public Health asked key informants about healthcare issues in their community. When asked how much they believed physical environment and social determinants of health contribute to health problems in the county, most ranked social determinants (such as alcohol/drug abuse, economy, and education) as a major contributor. However, their top health priority was access to care. This suggests that residents are aware of the importance of primary care as an upstream factor impacting their overall ability to access healthcare. To address this issue, we cannot overlook the socioeconomic barriers that individuals face to access, as well as the other challenges happening in their lives simultaneously.

Sources: Graham County CHA.pdf

Free Lyft to the Pharmacy

Blue Cross and Blue Shield Institute has started a partnership with the ride sharing company Lyft to provide their members with free rides to pick up their medications. The Blue Cross Blue Shield Institute is a new organization that’s mission is to reduce the barriers of accessing healthcare. One of the largest identified barriers to accessing healthcare is transportation. Last year, their big initiative was a similar program with Lyft to provide free transportation for their patients to their doctors’ appointments. By investing in these types of programs, the organization is hoping to reduce costs in the long -term and improve the health outcomes of their consumers. With this newest imitative they are also partnering with pharmaceutical organization such as CVS Health and Walgreens to increase medication adherence. These programs are still under pilot testing and are currently funded by CVS and Walgreens in Chicago and Pittsburgh with patients who are living in “transportation deserts”. These types of unique partnerships are allowing for creative solutions and addressing the social determinants of health in order to solve the most dire healthcare problems. Let’s hope to see more of these types of collaborations in the future.