September 2019: Leading health systems tackle the structural determinants of health


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Vol 2 Issue 9

Dear friends,

“So what does moving upstream mean?” A pediatrician recently asked us that question during a session with Harvard’s Center for Primary Care. Well, as the National Academies of Science, Engineering, and Medicine outlined yesterday, we know that moving upstream means improving patients’ care by addressing their social needs. That’s certainly what HealthBegins helps partners do. But to us, moving upstream means so much more.


This week HealthBegins hosted a webinar with two of the nation’s largest health systems that demonstrated the broader answer: moving upstream means healthcare and community partners working together to continuously improve social drivers of health at all levels, from individual social needs and community-level social determinants to the societal causes of the causes — the structural determinants of health.


Federal policies, structural racism, the climate crisis, or voting barriers might seem far removed from the clinic, but they’re important structural determinants of health. They impact our patients’ health and healthcare in powerful ways.


In our webinar, two prominent Upstreamists told us how their healthcare institutions are not just improving social needs — they’re also tackling structural determinants of health in concrete ways. Dr. Dave Chokshi is chief population health officer at New York City Health + Hospitals, the largest public healthcare system in the country. Berenice Núñez Constant is vice president of government relations at AltaMed Health, the nation’s largest federally qualified health center. And the experience and advice that Dave and Berenice shared on Tuesday about their institutions’ work on the federal public charge rule and voter registration showed us that healthcare can and does, in fact, play a critical role in shaping structural determinants.

More than 500 of you registered, but if you missed the live webinar, I don’t want to give away too many details. You can find valuable ideas and insights from Dave and Berenice in the freely available recording. Here are some top-level highlights…


In New York City, Dave and his colleagues were already pursuing a multi-level strategy to address social needs such as food and housing. But when NYC Health + Hospitals saw the new federal public charge rule, they knew it was critical for them to respond. The health system is now taking action at multiple levels: educating patients and staff about the policy, referring patients to legal help through its medical-legal partnership, and joining a lawsuit with the city and state of New York to stop the rule.


In Southern California, Berenice Núñez Constant and her colleagues are using the power of their deep relationships with communities to address another structural determinant of health: voting barriers.


(It’s not an accident that we held our webinar on National Voter Registration Day! You can find resources for encouraging voting at that link.)


To tackle structural barriers to voting, AltaMed is developing a scalable blueprint for what it calls “clinic-based mobilization,” targeting low-propensity Latino voters, and the results so far are amazing. Precincts that AltaMed targeted in L.A. County in the 2018 midterm election saw a 12-percentage-point turnout increase over 2014. And for every 1 percent of total voters in a precinct that AltaMed contacted, the turnout increased by 8.3 percent!


In the end, our inspiring panelists left us with a message that I want to underscore: Don’t be daunted! Moving from social needs to structural determinants can seem overwhelming. But there are manageable ways to start making an impact. Here are four important steps for health systems:

  1. Develop a deeper understanding of structural determinants. It’s hard to act on these conditions if you don’t understand how they affect your patients’ daily lives.
  2. Cultivate authentic relationships with non-clinical experts who address structural determinants for your patients and community.
  3. Find and take at least one concrete action to address structural determinants for your constituents, as individuals and as an institution. 
  4. Update your overall upstream strategy to encompass this structural level of health. 

Finally, and as always, if you want to learn more about how to advance a strategy to address structural determinants, contact us. As Paul Farmer once reminded me, “health is created with others, just as we can together dismantle systems” that cause suffering. We can navigate upstream better — improving social drivers of health at all levels — when we do it together.


Rishi Manchanda


From The Upstreamist, the HealthBegins Blog:From Transactional to Transformational: The Next Level of Upstream Care

“Give a man a fish and you feed him for a day; teach him to fish and you feed him for a lifetime.” But what if he can’t afford the lesson? What if the pond is polluted? Why not teach a woman to fish? This post calls us to drive change on all levels of scale.

When Moving Upstream, Don’t Go Chasing Waterfalls

With so many emerging initiatives and projects to address social needs and social determinants of health, the opportunity to improve the lives of patients and communities is more real than ever. But we face a real risk of squandering this opportunity.

Time to Manage Upstream Programs Like Investments

Through partnerships and collaboratives, healthcare organizations are launching programs to address social needs and social determinants of health. We have budgets and plans to reach specific goals, but is the way we’re spending our resources putting us on a path to achieve long-term goals for community health? At the moment, the answer is no. In this post, Rishi Manchanda outlines why it’s time to view upstream interventions as investments for long-term financial, health, and social impact.


Watch our September webinar:

From Public Charge to Voting: Five ways healthcare leaders can tackle structural determinants of health

A famous proverb states: “Give a man a fish and you feed him for a day; teach him to fish and you feed him for a lifetime.” But what if he can’t afford the lesson? What if the pond is polluted? Why not teach a woman instead?

As healthcare and community partners work to improve care and individual health-related social needs, there is growing acknowledgment of a fundamental challenge. Even the most effective relationships between healthcare and social services still take place in unequal systems, where the communities in which patients live and work are shaped by unjust structures and unhealthy policies — what the WHO calls the “the causes of the causes.”

This webinar brought together leaders from the nation’s largest FQHC and the nation’s largest public healthcare system to highlight real-world examples of ways institutions are adding systems and structural transformation to their upstream investment portfolios. We discussed the potential impact of the new proposed public charge rule, due to go into effect in October, and what healthcare systems can do to prepare and respond. And, in honor of National Voter Registration Day (Sept 24th), we provided concrete examples of how to address one of the most significant upstream drivers of health — voter and civic engagement. Finally, drawing on real-life examples, we identified five specific ways healthcare leaders can support efforts to transform health policy and structural determinants of health across America.

Interested in more webinars from HealthBegins? You can find recordings of all of our past webinars here.

Upcoming and Recent Events: Find HealthBegins Here

ConsejoSano Reaching Out(comes): The Role of Text Messaging in Healthcare
October 10 | BurbankConsejoSano’s first annual conference on best practices to meet the health needs of low income and multicultural healthcare consumers.The Root Cause Coalition National Summit
October 21 | San Diego

An event where attendees discuss the social determinants of health and the work being done to address health equity.

Southern California Association of Non-Profit Housing Annual Conference
October 25 | Los Angeles

Affordable housing advocates, developers, and stakeholders come together to learn about and discuss health equity.

Presenting powerful upstream results at an upcoming conference? Nominate yourself to be featured as a HealthBegins Upstreamist in Action at

Upstream Opportunities:

From the San Diego Hunger Coalition and the Community Benefits Department Sharp CME: Opportunity to learn more about food insecurity

Part 1 – Definition, Policy and Health Outcomes
Part 2 – Screening Patients for Food Insecurity
Part 3 – Connecting Patients to Food Resources
Part 4 – Evaluation, Sustainability and Advocacy

If you have fellowships, events, or other opportunities you’d like us to share, please email us at

Upstream News

Curated highlights of happenings affecting upstream care. Links are not endorsements.

Major New Report Calls for Better Integration of Social Determinants of Health
Healthcare IT News

Social Justice is the Foundation of Healthcare — and Medical Education
The Philadelphia Inquirer

Most Providers Don’t Screen for Social Determinants of Health
Modern Healthcare

Family Support Most Requested of Social Determinants of Health
Patient Engagement HIT

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