Physician and Writer Rishi Manchanda

The physician discusses ‘upstream’ healthcare.

Dr. Rishi Manchanda is a physician, author and healthcare leader who has spent more than a decade developing novel strategies to help patients in resource-poor communities. He served as director of social medicine for a network of community clinics in south central Los Angeles, as the lead physician for homeless Veterans at the Greater Los Angeles VA, and as chief medical officer for a company with a large rural immigrant workforce. In his 2013 TEDbook, The Upstream Doctors, he introduced a new model of healthcare workers who improve care by addressing patients' health-related social needs, like hunger, housing insecurity, and poverty. He tells the National Health Service Corps, "The moment when a patient switches from despair to hope is the greatest part of my service."

Dr. Manchanda is President of HealthBegins, a social enterprise that provides healthcare professionals and community partners with tools to improve care and the social factors that make people sick in the first place.

Follow Rishi Manchanda MD on Twitter @RishiManchanda.


Tavis Smiley: Good evening from Los Angeles. I’m Tavis Smiley.

Tonight, as part of our Road to Health series, first a conversation with Dr. Rishi Manchanda. He’s part of a new generation of healthcare practitioners who believe that health, like sickness, begins in the places we live, work and play.

Then, Academy Award-winner Melissa Leo joins us to talk about her starring role in Showtime’s new series, “I’m Dying Up Here”.

We’re glad you’ve joined us. All of that coming up in just a moment.

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Tavis: And by the Robert Wood Johnson Foundation working with diverse partners to build a national culture of health so that everyone in America can live productive and healthy lives.

The California Endowment. Health happens in neighborhoods. Learn more.

Announcer: And by contributions to your PBS station from viewers like you. Thank you.

Tavis: Pleased to welcome Dr. Rishi Manchanda to this program. He is part of a new generation of healthcare practitioners who specialize and see health, like sickness, as more than a chemical equation that can be balanced with just pills and procedures.

Rather, health, like sickness, begins in our everyday lives in the places where we live, work, eat and play. So I’m pleased to have Dr. Manchanda on this program as we continue our Road to Health series on this program. Doc, good to have you on.

Dr. Rishi Manchanda: Thank you so much.

Tavis: I’ve been reading about your work, and you refer to yourself as an upstreamist. What’s that mean?

Manchanda: So the upstreamist term comes from a parable t hat I heard early in my career and I adopted and made it my own. The parable is as follows. Three friends come to a river. It’s a beautiful scene. Unfortunately, something really tragic happens.

There are people in the water, children, adults, the elderly, all drowning. The three friends who come to the river jump right in save those. The first friend actually says, “I’m a strong swimmer. I’m going to go to the waterfall’s edge. I’m going to save those about to drown.”

And the rest of us now who’ve amassed along the banks of the river say, “That makes sense. Rescue those about to drown.” The second friend meanwhile says, “Let me swim a little further upstream. I’ll coordinate some of the branches along the banks of the river and I’ll build a raft and I’ll usher more people to safety.”

Over some time, the success rate is marginal. You know, they’re saving people. They’re doing noble, heroic work, but something happens. They get a little fatigued, a little tired. They start saying things like, “Didn’t someone teach you how to swim?”, to people in the water.

And then they realize, “Wait. The third friend. Where is she?” And they look up and they see her and she’s in the water. She’s saving people, but she’s swimming away from them. They say, “Where are you going? There are people here to save.” And she’s saving people as she’s going. She’s doing the work.

She shouts back, “I know. I’m going to find out who or what is throwing these people in the water.” In the healthcare workforce, we have the downstream rescuers. We have the raft builders, those the primary care folks. We’ve always had the third friend, though.

I think what I call the upstreamist is that third friend, the healthcare practitioner whose job it is to routinely understand where people live, where they work and, as importantly, Tavis, figure out how to translate that knowledge into actions so that we can prevent more people from falling in the water.

Tavis: To take your parable a step further, if I may, who then is throwing these folk in the water, these people who are being subjected to unhealthy conditions where they live, where they work, no access to high-quality foods? I mean, who’s throwing these folk in the water?

Manchanda: You’d end it. So the who or the what is actually instructive there because the what speaks to what we in the public health and the social science world and the political science world have long known. These are the structural causes, the isms, right?

These are historic generational kind of forces that often define the nature of a neighborhood and, more importantly, what is not sometimes in a neighborhood. The access to the healthy food, the parks, etc. It’s sometimes who. This goes to what some political scientists call not just the social determinacy of health, but the political determinacy of health.

We know, I mean, now more than ever that discussions in D.C., in state capitols around the allocation of resources, policy, those have meaningful impacts right now in healthcare, who has access to healthcare, who doesn’t. These are the choices that ultimately define the nature of who falls in the water and who doesn’t.

Tavis: Let me be crass about this. I apologize in advance. So it seems to me, with all three of those friends who were saving people in various ways, there’s money to be made. But the real money to be made is being made by the folk who are throwing them in the water in the first place because as long as there are people who are suffering in this way, there’s money to be made top down. You take my point here.

Manchanda: I hear you.

Tavis: What do we do about the people who are in this because there’s money to be made and, if everybody were healthy, you included would be out of work?

Manchanda: Yeah. There’s this idyllic vision that motivates a lot of doctors who enter the workforce and are in still to say, “Give us the tools and the technologies and the skills to learn how to take care of those who are downstream”. But there are always doctors who say, “I went into medicine to help people and helping people isn’t just mending them when they’re about to fall over the waterfall, but figuring out how to prevent that in the first place.”

Look, I think, to your point, it’s a well-taken point. Who’s profiting? It gets to this question of why do we have a system like this where we don’t have enough upstreamists, maybe why we don’t have enough people — why we have too many people in the water? It’s financial. There’s clearly incentives and I think, unfortunately, it’s not just one villain. I think we’ve all made choices.

Tavis: It’s a network.

Manchanda: It’s a network and it’s…

Tavis: I take that.

Manchanda: It’s happened over decades, you know. And in some ways, it’s happened on both sides of the aisle. It’s beyond political kind of ideology. There has been this belief that healthcare itself is based on volume. Let’s pay for volume and not value. So let’s pay for every service you get and not for how healthy we ultimately make you.

That’s shifting now. That started happening about 10 years ago. The Affordable Care Act, Obamacare, actually helped to solidify some of the changes towards value that were happening. But the takeaway is this. As this is happening, as everybody has some responsibility in this, including physicians, including hospitals, including communities and including policy makers, I know every day in the clinics in Los Angeles, in cities around the country, we can’t afford to wait to find who’s responsible.

We have to act because you have too many people coming into the clinics in South L.A. where I used to work, in the VA system where I took care of homeless veterans, in clinics up and down California with colleagues who continuously say, “Look, my patients are coming in because of headaches due to mold infestations in their home.

Give me the tools and the teams that I need to be able to take care of that and not just prescribe pills.” We need to figure out ways to act and that’s what the upstream approach to healthcare is all about.

Tavis: Who cares enough about that reality to do anything about it? Because, I mean, this is not a skill challenge. It’s a will challenge. Do we have the will? We know we have the skill. But who cares enough about it to put their skill to good use to fix the problem?

Manchanda: You put your finger on it. I mean, just to underscore your point, in a survey done about five years ago of physicians nationwide, 90% of physicians said that their patients’ social needs were as important as their medical problems. That’s for some an eye-opening figure.

The problem is that only one in five of those physicians believe they had any ability to do something about it. They lack the confidence, the sense of efficacy. So you’re right. It’s a challenge not of knowledge. It’s a challenge of will and really not why, but how.

There’s a couple of things that have happened and this is part of the reason that folks like myself who’ve been talking about the upstream thing are now getting some opportunities like this.

When you start having people who are paying for healthcare, whether it’s individuals, whether it’s self-insured employers who are aligned to see the value out of what they’re getting, when you see public payers like Medicare and Medicaid and others, start saying, “Look, maybe we shouldn’t continue to pay for every service.

What’s happening is untenable. We’re spending two and a half times more than any other nation on healthcare, but we’re getting less return on investment. We’re less healthy than our peer nations. Something’s not working.”

When you have those payers, as has been happening in the past five  years, start asking, “Give us value, not just volume”, and forcing the healthcare system to come to terms with that, it’s creating an opportunity where the value conversations are coming into play with the upstream lens and that’s the moment we’re in right now.

What remains to be seen — and I’m the first person to both evangelize and also be a skeptic — the question of the moment right now, the challenge we have, is this urgency of now, is to figure out how to capitalize on this opportunity to demonstrate that this upstream approach really works. And I think this is the first time, frankly, in a generation that we can do that.

Tavis: Why do you think that the timing is propitious now for doing that successfully?

Manchanda: I think there’s a little bit of a tipping point emerging. It has been happening over the past 10 years of those folks who are paying the bill are starting to ask for better value. I think it’s because of an awakening culturally. I think patients, community members, are starting to have a voice in the healthcare conversation, whereas before it was often doctor knows best.

So I think there’s a cultural democratic kind of nature that is inviting more people to have a voice. I think it’s also something about this moment that we’re in historically, right? Where we’re realizing that we’re all in this together.

If you have a part of our economy that’s taking up more than 20 cents out of every dollar that we spend and that’s robbing other opportunities to invest in education, to invest in public health, to invest in transportation, to invest in girding up the neighborhoods of America, there’s this set of questions.

And I think what we saw at the election, for instance, is an awakening of the pain that’s out there in many different communities that was previously blind. Some people were blind to it in other communities and vice versa.

There was a lot of, I think, eye-opening experiences, painful as they were, during the election process. And I think now people are saying, “Clearly, something’s broken. Let’s fix it.”

Tavis: Let me return one last time in this conversation to your analogy of those three friends in the water. I don’t want to get in too much trouble with Black folk and their lack of buoyance when it comes to swimming. You’ll take the joke.

But it seems to me that the disproportionate number of folk who are drowning in that water are Black and Brown for whatever reasons. They’re unable to swim and they’re Black and Brown. So while we hypothesize about this and talk about how to capitalize this and how to address this, you got folk in the water who are still dying, disproportionately people of color. What do we do about that while we’re trying to fix this?

Manchanda: Yeah. You’re exactly right. There are a lot of folks on the payer side saying, “We care about value” and one of the important things, to your point, is that we have to, A, ground this conversation in values and that includes justice. That includes fairness, equity.

There is no doubt that, as payers and healthcare providers and public health folks, try to capitalize on this opportunity at this moment, we have to be mindful of the lopsided nature of health and illness in America.

The reason for those disparities is in large part because of those policies that have long — structural racism especially — that has long been codified in our nation’s policies, that has a direct influence on the distribution of disparities in Black and Brown communities.

What I think is important right now is to figure out ways to be able to have the conversation about what we so need in this country, which is more upstream investments.

Compared to all of our peer nations, we are the only country that has a lopsided ratio of spending. We spend more on healthcare than we do on social services. You go to other peer nations, this is the opposite. It’s called the American healthcare paradox and there’s no surprise then to those in the know who are in communities and not just professionals that’s why we have a lot of these disparities.

We’re investing in the wrong places. We’re not investing in communities and we’re certainly not investing in communities that have historically been marginalized and continue to be marginalized because of these choices.

Part of what my role as a doctor is to bear witness and then to figure out how to invite others in to this conversation about changes we have to make to be value-based and values-driven. It has to be based in a framework of equity and justice.

Tavis: Indeed it does. Rishi, good to have you on.

Manchanda: Thank you.

Tavis: Thanks for your work, Doc. Up next, actress Melissa Leo. Stay with us.

Announcer: For more information on todays’ show, visit Tavis Smiley at

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Tavis: And by the Robert Wood Johnson Foundation working with diverse partners to build a national culture of health so that everyone in America can live productive and healthy lives.

The California Endowment. Health happens in neighborhoods. Learn more.

Announcer: And by contributions to your PBS station from viewers like you. Thank you.

Last modified: July 5, 2017 at 2:23 pm