Intended for healthcare professionals

Observations Letter from New England

Fishing upstream: health and the social history

BMJ 2015; 350 doi: (Published 05 May 2015) Cite this as: BMJ 2015;350:h2378
  1. David Loxterkamp, medical director, Seaport Community Health Center, Belfast, Maine
  1. david.loxterkamp{at}

The importance of determining the social determinants of health

It is now fashionable (even in the United States) for doctors to talk about social determinants of health. Polls show that access to healthy and affordable food, controlling drug misuse, and cleaning up the environment are seen as more important to people’s health than access to high quality medical care.1 Groups such as Health Leads train doctors to identify their patients’ social needs and to link them to community resources.2

Malcolm Gladwell introduced us to Million-Dollar Murray in 2006.3 Atul Gawande wrote about Jeff Brenner’s work among the “hot-spotters” of Camden, New Jersey, in 2011.4 Both sounded the alarm that unmet psychosocial needs have led to overuse of the healthcare system, largely because emergency departments and hospital wards have become society’s safety net. More recently, Rishi Manchada focused our attention on “upstream doctors” who look beyond the symptoms of disease to their source in the community.5 He estimated that the conditions under which people lived and worked had five times the impact on health and disease as all the pills and procedures in our medical quiver.

Challenges for family medicine

Of course, family …

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