Health Equity

Why COVID-19 makes it more important than ever to look upstream

Marc Zarefsky , Contributing News Writer

From his home in Los Angeles, Rishi Manchanda, MD, MPH, searched for words to describe the COVID-19 pandemic. As the number of new cases across the country spiked to more than 50,000 per day, his city and home state of California joined more than a dozen other states in either reversing or pausing their reopening plans.

Explore Health Equity

This web series features diverse speakers touching on the impact of existing structural issues and the COVID-19 pandemic on health equity.

After a pause, Dr. Manchanda, found the words he was looking for. 

“It’s a remarkable moment, because the pandemic is laying bare … that moving upstream means looking at the things we can’t see—the structures, the forces, the environment and the policies that shape people’s lives,” he said during a virtual panel discussion about moving upstream to reimagine, redesign and reconstruct what a more equitable health care system can look like. “This pandemic has made it possible for more people to look at what is hard to see. And that’s stirring, but it’s also sobering.”

Dr. Manchanda is CEO at HealthBegins, a mission-driven advisory firm that works with health plans, health systems, public health departments and community organizations to build out their strategies to address social drivers of health and equity. He spoke as part of “Prioritizing Equity: Moving Upstream,” the latest installment in the AMA’s YouTube health equity series.

The conversation about how some organizations are working toward a more equitable heath care system featured three other physician and health equity leaders and was moderated by Aletha Maybank, MD, MPH, chief health equity officer and group vice president of the AMA.

The AMA and the Centers for Disease Control and Prevention (CDC) are closely monitoring the COVID-19 pandemic. Learn more at the AMA COVID-19 resource center. Also check out the AMA’s physician guide to COVID-19 and get guidance from the AMA on reopening amid COVID-19.

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The AMA is carefully compiling critical health equity resources from across the web to shine a light on the structural issues that contribute to and could exacerbate already existing inequities. A New York Times analysis of CDC data recently found that the rate of coronavirus cases per 10,000 people stood at 73 for Latinos, 62 for African Americans, and 23 among whites.

At HealthBegins, Dr. Manchanda and his colleagues help front-line clinicians and community partners attempt to address the conditions that make people sick in the first place.

Moving upstream, he said, “means continuously improving the social drivers of health and equity at all level— individual social needs, community-level social determinants of health, and structural determinants of health equity.”

He added that “because the underlying structures in the U.S. that propagate inequity and perpetuate disproportionate disease and death are unequal, when systems talk about moving upstream but don’t do it the right way, which is to make sure it’s addressing all three layers, they can actually aid and abet in perpetuating the status quo.”  



Like Dr. Manchanda, Sandra Hernández, MD has paid close attention to the resurgence of COVID-19 cases in California as president and CEO of the California Health Care Foundation (CHCF).

One way the foundation has moved upstream is by joining forces with the other funders to determine how they can work together to best help during the pandemic. 

She also noted that COVID-19 has brought with it the chance to change the perspective of what the health care system is and who it actually should be built around. There is an opportunity, she said, “to really shift the paradigm from a clinician- or physician-centered health care delivery system to something that is more consumer-driven.”

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A clear example of this shift is telehealth, Dr. Hernández said. Instead of forcing patients to travel to offices that would not be safe, physicians across the country have adopted or expanded telehealth opportunities so that patients can get the care they need when they need it and in a safe way.

“We need to figure out how to create a delivery system that is responsive at the point of care,” Dr. Hernández said. “This pandemic is allowing us to do that—and do it at scale.”

Lauren R. Powell, MPA, PhD, executive director of Time’s Up Healthcare, and David Zuckerman, MPP, director of health care engagement for The Democracy Collaborative, also took part in the panel discussion.

Learn more about the health equity education on the AMA Ed Hub™ featuring CME from the AMA’s Center for Health Equity and curated education from collaborating organizations. To earn CME on the AMA’s “Prioritizing Equity” videos, visit the courses page on AMA Ed Hub™.