The upstream–downstream tension in the global health classroom

Abstract

In this practice paper, we reflect on our practices, experiences and observations of teaching global and public health, with a focus on navigating the upstream–downstream tension. The concept of upstream determination of health encompasses how the social, structural and systemic drivers shape health and well-being. This paper discusses the challenges of foregrounding this concept in pedagogy through four key themes: (1) a lack of uniformity in integrating upstream concepts across disciplines related to health, and the ways in which it could be better integrated specifically into global health curricula; (2) helping students navigate the upstream–downstream tension by reflecting on why downstream solutions are more prevalent and how to better understand the structural responses, which are needed for achieving health equity; (3) why upstream thinking is hard to teach and learn, given that upstream determination can be complex, less familiar and abstract (we outline conceptual barriers and pedagogical challenges, common missteps and potential strategies to overcome them); (4) looking upstream in global health roles; how future graduates may consider ways to work upstream in their role as global health professionals, given that many job opportunities tend to focus downstream. This paper highlights the challenges of teaching upstream determination in global health, with a call to more uniformly integrate its concepts into curricula and offers potential strategies for teachers to meaningfully and collectively foreground such concepts within pedagogical delivery.

SUMMARY BOX.

• Addressing the root causes of ill-health is widely understood in most disciplines related to global health, especially when health equity and social justice are of particular concern.

• The concept of upstream determination of health is foundational in global health. However, its practical integration into teaching and training remains limited and uneven.

• We examine how upstream thinking can be incorporated in global health curricula and in global health classrooms, including associated pedagogical practices and challenges.

• The reflections presented in this article are based on our own practices, experiences and observations of tendencies in global health curricula and teaching around the world.

• We propose potential strategies to integrate upstream thinking into global health education and equip teachers and students to engage with the upstream determination of health.

Introduction

In nearly every global health classroom or training programme, a moment arrives when students ask why health inequity persists, and what can be done about it. While there is no single answer, the why question unlocks discussions rooted in structural forces—colonial legacies, systemic discrimination and neoliberal policy frameworks—that shape how society functions, entrenching health inequities. The why question opens spaces for students—and for us as teachers—to articulate a deeper understanding of the structures and systems that sustain global patterns of inequity, and the mechanisms by which they maintain global patterns of inequity (ie, the how). The what to do about it question further demands pedagogical creativity and bold strategies rooted in social justice.

Long used as a metaphor to conceptualise the structures and systems that determine health and equity, we have found the upstream–downstream framing useful in our efforts to explain why health inequity persists, how structures and systems maintain inequity, and what can be done about it.¹,⁴ John McKinlay’s 1975 article illustrates the metaphor through a parable⁴ :

There I am standing by the shore of a swiftly flowing river and I hear the cry of a drowning man. So I jump into the river, put my arms around him, pull him to shore and apply artificial respiration. Just when he begins to breathe, there is another cry for help. So I jump into the river, reach him, pull him to shore, apply artificial respiration, and then just as he begins to breathe, another cry for help. So back in the river again, reaching, pulling, applying, breathing and then another yell. Again and again, without end, goes the sequence. You know, I am so busy jumping in, pulling them to shore, applying artificial respiration, that I have no time to see who the hell is upstream pushing them all in.

Thinking in global health is often done with a view to specific behaviours and isolated risk factors impacting health outcomes. Instead, we ought to consider upstream issues not through a linear set of determinants but rather through a multidimensional process (upstream determination) consisting of the social, structural and systemic drivers impacting health outcomes.^{5 6} As a field, Global Health has historically prioritised downstream approaches to public health challenges—with interventions that do not directly disrupt the structural and systemic forces, which shape and perpetuate health inequity. Whether it is building a water well, using technological tools like digital applications to improve dietary or mental health outcomes, or developing new pharmaceuticals, downstream solutions (while essential and indispensable) focus on addressing symptoms rather than root causes.

Knowing what to do about entrenched inequity requires understanding how social hierarchies and institutionalised discrimination is mapped into physiology and social relations through repeated and unequal exposures to material deprivation, environmental hazards and psychosocial stressors.⁷,¹⁰ It requires understanding how these long-standing exposures result in physiological dysregulation and social dysfunction, how the cumulative burden of such stressors is passed across generations and increases susceptibility to physical disease and social vulnerabilities, particularly among marginalised populations.⁸¹¹,¹³ However, these multilevel, interactive, non-linear structural power arrangements are often invisible and normalised, even as they systematically shape health outcomes in a population, underscoring the importance of equipping global health students with conceptual and empirical tools to recognise, analyse and disrupt these mechanisms.^{8 13 14}

Despite general agreement on the need to foreground upstream determination, ours and others’ experience suggests its integration in practice as a primary focus of global health pedagogy remains limited.⁶¹³,²⁰ This limitation undermines students’ ability to recognise how population-level patterns emerge, how causes operate across time and systems and how institutions embed unequal distributions of risk and ill health.^{8 12 14} We have found that although challenging, teaching upstream thinking enables learners to move beyond linear causal reasoning, grapple with feedback loops and interdependencies and apply analytical tools suited for complex, multilevel health and equity problems.¹³ It also challenges the assumption that health disparities are best addressed through individual-level interventions, reinforcing the need for upstream determination. Without this foundational ability to think upstream, future global health professionals are less equipped to critically assess dominant paradigms or propose transformative responses to health inequity.^{15 16}

Lack of uniformity in fields of study

Any discipline concerned with improving the health and well-being of marginalised populations would benefit from curricula that provide a theoretical and practical grounding on the complex root causes of health inequity.^{14 20 21} Yet, this is not uniform across disciplines and institutions. Fields related to health and health equity—such as global health, public health, health promotion, environmental health and health policy—often lean more towards either the social sciences (eg, a training programme based in a social science faculty) and/or the biomedical sciences (eg, a training programme based in a medical school) shaped by the epistemic culture of the host discipline.^{22 23} Those who lean more social tend to focus more upstream compared with clinical disciplines like medicine and allied health. However, even in these latter disciplines where a downstream focus predominates, the limitations of such approaches in the face of upstream disadvantage are still implicitly or explicitly recognised.²⁴,²⁷ As healthcare workers treat and support patients who face upstream disadvantage, they recognise the futility of prescribing treatments that may provide only temporary, localised relief while leaving the upstream determination of poor health unaddressed.²⁸ While aspects of upstream thinking are generally introduced in health and medical education,^{22 29 30} the degree to which it is meaningfully embraced and understood, especially with a view to individual or collective action, is still unclear.

In fields related to health and health equity, there is also perhaps a lack of uniformity in the design and delivery of curriculum, which integrates upstream thinking and action. In global health and public health, which ought to be normatively equity and justice oriented, there may be greater pressure to centre upstream thinking and action, compared with health policy or health promotion, whose framing may include, but may not be primarily focused on, equity and justice.²² In global health education, there have been calls to incorporate an understanding of political processes into curricula through interdisciplinary thinking and equitable partnerships with grassroots practitioners and activists, for cross-learning opportunities to deliver upstream-related content together with actors, such as activists, that engage primarily upstream.^{29 31 32} However, a coordinated effort in curriculum development and experience sharing is needed to embed theoretical and practical approaches to upstream determination, such that these concepts are not treated as peripheral or as a mere ‘assignment task’ but as essential tools future graduates can carry into clinical and public health practice.^{14 15 17}

Navigating the upstream–downstream tension

Introducing upstream determination of health inequity to students often triggers questions on the value of downstream solutions. We explain that downstream solutions do hold value. People are suffering in real time and solutions are needed quickly. However, in global health practice, preference for these solutions is frequently shaped by neoliberal or power-mediated dynamics, where the global North (or more powerful actors within a country) impose capitalistic, corporate-driven agendas, methods and products to ‘fix’ health problems in the global South (or among less powerful groups within a country).⁹ We remind students that although such practices may be changing, this shift is currently slow, uneven and has to undo the entrenched practices of social and epistemic injustice, which have already unfairly impacted the agency of those most marginalised in their ability to advocate for upstream solutions or to even recognise that such opportunities are possible.^{9 33}

To help students navigate this tension, we emphasise the importance of structural literacy and shared knowledge. We explain that a person of a low socioeconomic position living in a ‘low-income’ country, for instance, would only secure a healthy life within the constraints of the broader structures that shape the conditions under which they live—their access to sanitation systems, adequate housing, economic stability, educational services and healthcare facilities. That person’s health is shaped by the systems that produce socioeconomic disadvantage and by the global structures that positioned their country as ‘low-income’ in the first place. Understanding how to dismantle structural barriers to health must include making that knowledge accessible to the communities whose lives are most affected. Even when the person and their community understand the upstream determination affecting their well-being, the resources and decision-making power needed to act on that understanding are often concentrated among actors who often focus downstream. In classroom discussions and debates, we ask students to reflect on how a focus on downstream efforts—though well-intentioned—can reinforce deeper injustices when they disregard the broader systems that give rise to poor health in the first place. Framing health problems as solvable solely through downstream responses risks sending the message that upstream determination lies beyond reach. Instead, we encourage students to hold space for both immediate (downstream) responses and long-term or medium-term (upstream) transformation—and to develop the critical awareness needed to work across that divide.

To reinforce, it would be reductive for educators to only suggest a focus on upstream. Downstream efforts are indeed often necessary, particularly in acute or volatile settings like emergency care or humanitarian crises. However, a useful task is to help students think critically about the trade-offs between downstream and upstream approaches. Downstream strategies tend to be more discrete, tangible and implementable in policy and practice—and therefore more attractive—than upstream ones, especially with the use of technology. For example, using drones to deliver medicines to a remote village with poor road access may offer immediate relief, yet it can also entrench the status quo—a band-aid solution that bypasses structural investment to build roads and strengthening local supply chains, which has wider benefits including improved medicine availability at the clinic. We encourage students to interrogate the conditions that made the technological fix as necessary and viable. This kind of inquiry helps students move beyond binary thinking and towards a more nuanced understanding on how to align immediate responses with structural change.

We suggest to students that global health gravitates towards downstream strategies because we, those we work for, or those who fund our efforts, may favour interventions that preserve existing power structures. Many downstream interventions are easily commodified as private goods, making them profitable and appealing to wealthier and more powerful actors. Perhaps downstream solutions come readily to mind because we spend far less time considering upstream ones. Public goods like roads, sanitation and welfare systems may seem ‘not the job’ of a global health professional, yet ignoring such aspects of upstream determination only increases inequity and injustice over time.

Why upstream thinking is hard to teach and learn?

To teach upstream thinking effectively, we must first understand why it is so difficult to grasp—for students and educators alike—by recognising the deep cognitive and conceptual challenges it presents (see table 1). Structural and systemic forces like capitalism, racism, sexism, patriarchy or state power are often not directly observable; they are abstract, intangible and unfold over time through diffuse mechanisms.^{10 34 35} Students are typically more familiar with visible, immediate and personally experienced phenomena, which makes it harder to engage with indirect, collective forms of causality.³⁶ We do not perceive these abstractions intuitively, and thus they feel remote—even unreal—unless they are deliberately made visible through narrative, metaphor or modelling.

Table 1. Challenges and strategies for teaching upstream thinking.

Conceptual barrier	Challenge	Common missteps	Teaching strategy
The fuzzy boundaries between individual autonomy and upstream determination.	Students may struggle to understand how individual identity, experience and action are simultaneously autonomous and shaped by or embedded in larger systems. This leads to discomfort with thinking of the self as both autonomous and structurally constrained.	Framing individuals as entirely self-determining actors.    Teaching systemic effects as something that happens to ‘others’ (eg, vulnerable populations) but not to ‘us’.    Avoiding discussions that require interrogating students’ own positions within systems of power or privilege.	Encourage students to explore paradoxes of identity and interdependence. Use reflective exercises, case narratives and ‘systems within the self’ metaphors (eg, medical, psychological, or social systems within a person). Emphasise that individual lives are emergent properties of larger interactive forces.
Systems require thinking beyond direct observation.	Students may find it difficult to reason about causes they cannot see, especially when feedback is delayed or intangible (eg, how structural racism affects cellular ageing or chronic disease rates).	Relying only on observable symptoms or immediate feedback loops.    Presenting upstream factors as vague ‘background’ variables, not active mechanisms.    Avoiding teaching controversial or value-laden structural topics due to perceived lack of hard evidence.	Use metaphors (eg, gravity, climate systems) and scaffolded exercises to illustrate how real outcomes can be inferred from consistent patterns. Teach causal inference as a skill that includes historical and social reasoning, not just statistical modelling.
Structural thinking challenges dominant cultural narratives of merit and fairness.	Students may resist upstream thinking because it destabilises core beliefs about individual responsibility, achievement and fairness—especially when such beliefs align with their own educational and social mobility or status.	Skipping difficult conversations about race, class and structural advantage.    Framing health outcomes solely in terms of behaviour change or personal choice.    Teaching structural injustice as past history rather than ongoing reality.	Facilitate space for emotional and cognitive discomfort. Use storytelling, participatory dialogue and counterfactual thinking to examine how life trajectories are shaped by structures. Introduce concepts like structural humility and moral imagination to engage students without triggering defensiveness.
Systems are abstract and non-sensorial.	Structural forces are not part of lived, sensory experience; they are abstract, inferred and epistemically distant. This makes it difficult for students to reconcile personal agency with systemic constraint.	Teaching systemic concepts as lists of determinants without showing interconnection or emergence.      Over-relying on outcome-based case studies that don’t surface underlying structural forces.      Treating structural causes as optional or secondary to individual behaviour.      Using decontextualised statistics without interpreting underlying systems.      Framing systemic structures as static background conditions rather than active forces.	Use emergence metaphors and introduce concepts like critical realism and phenomenology to help students understand how silent macro-structures shape social phenomena and action. Encourage reflection on how individual identities are shaped by historical and systemic forces. Develop epistemic humility: one’s experience is local, but shaped by broader operating systems.
Systems operate in non-linear, interactive fashions.	Systems are interconnected and nonlinear, making them hard to internalise through traditional pedagogy. Students are usually taught with linear cause-effect models and concrete examples, which clash with the complexity and of systemic forces.	Teaching systems as static diagrams without emphasising feedback, adaptation and learning.    Relying solely on sequential logic models that ignore complexity.    Presenting upstream factors as disconnected topics rather than dynamic influences.	Use analogies, scaffolding and visual systems tools. Incorporate concept maps, layered timelines and ‘zooming in/out’ exercises to help students connect individual experience with structural forces. Teach metacognition and reflexivity explicitly—encouraging students to reflect on how their ways of knowing are shaped by what they are taught to value or ignore.
Focus on disease and symptoms limits recognition of their upstream causes.	Focus on disease and symptoms, while important in clinical training, obscures systemic causes. Health and medical training often centres organ-specific problems and immediate interventions, reinforcing a downstream mindset. Upstream causes—cultural, political, economic, historical—are external to typical medical epistemologies.	Framing diseases strictly in biomedical terms without context.    Teaching clinical skills without linking them to social context or structural factors.    Neglecting patient histories that include environmental or occupational exposures.	Teach interdependence and system-wide effects. Use the human body as a metaphor for interconnected systems. Encourage students to ask how systemic conditions manifest in localised symptoms. Foster inquiry into ‘why this patient, in this context, at this time’? rather than just ‘what’s wrong’?
Disconnection between individual risk and population structures.	Difficulty connecting individual risk with population-level structures. Students often view epidemiological data in decontextualised ways, focusing on risk factors without understanding how those factors are structured socio-politically and historically.	Treating social exposures (eg, poverty, environmental injustice) as confounders to control rather than core causal agents.    Using statistical models without connecting data patterns to lived, shared experience.    Failing to incorporate historical context in interpreting concurrent risk factors.	Combine population modelling with structural storytelling. Use longitudinal studies and syndemic models to trace how social exposures (e.g., discrimination, chronic stress) become biologically embedded. Pair statistical methods with political and historical narratives to make visible how population-level patterns cluster and emerge from structural forces.
Cognitive bias favours simple explanations.	Human cognition favours salience, linearity and individual-level attribution. Our brains are not naturally equipped to track delayed, distributed and complex causality. This results in misattributions of blame and simplistic solutions.	Explaining behaviour or health outcomes by personal choice alone.    Ignoring probabilistic and cumulative effects of structural conditions.    Using oversimplified cause–effect narratives in teaching cases.	Scaffold complexity and counteract bias. Teach students about cognitive shortcuts (eg, fundamental attribution error, salience bias, confirmation bias) and how these shape health narratives. Use visual tools like causal loop diagrams and mental models to show how seemingly simple phenomena arise from complex systems. Emphasise that structural thinking is a learnt, not intuitive, skill.

A law passed decades ago or a trade policy enacted at the international level may eventually shape access to medicines or exposure to risk, but these connections are not self-evident. Because such forces operate across systems and time, they lack a clear agent to hold responsible. This diffuseness weakens moral urgency and makes accountability elusive. Meanwhile, these same systems are often normalised and rendered invisible in daily life—making their structural nature feel ‘ordinary’ rather than constructed.^{36 37} For students, recognising such forces requires not only conceptual tools but also metacognitive skills: the ability to reflect on what they take for granted, how knowledge is constructed, and who has the power to define what counts as a ‘solution’.

These challenges are compounded by how educational systems are organised. Disciplinary boundaries tend to separate the clinical from the structural, the biological from the political and the technical from the social. To cultivate upstream thinking, educators must work across disciplines and epistemologies.³⁶ This requires helping students see how nested systems interact—from personal behaviours to institutional structures to historical forces. It also calls for tracing causal pathways that move between levels and do not follow a linear trajectory. Pedagogical strategies must intentionally bridge the gap between the seen and unseen, the local and the structural.^{36 38} Concept maps, timelines and systems diagrams can help visualise invisible forces and historical counterfactuals and simulation exercises can prompt students to think in terms of possibility rather than inevitability.³⁹ Critically, students need opportunities to zoom in and out—to examine how everyday clinical or community-level problems are shaped by larger patterns of power, policy and history. By doing so, they begin to recognise that upstream thinking is not just a matter of additional learning material; it requires a shift in how problems are framed, which questions are asked, and whose knowledge is centred in the search for solutions.^{38 39} This pedagogical process is important not only for students but also for teachers, acting as a constant reminder for us to self-reflect and practise what we teach, individually and collectively.

Looking upstream in global health roles

While its mechanisms can be abstract or difficult to observe directly, upstream determination often takes institutional and operational forms. It may be embedded via organisational practices (eg, through active participation in governance, practice guidelines or leadership roles) or formalised through institutions (eg, laws, rights and policies). It can also be less formalised but harness equally powerful social dynamics, such as fostering social inclusion and harmony or challenging unjust social norms and discriminatory ideologies. The form that upstream determination takes depends on the positionality, resources and networks of the actors involved. Upstream determination can also involve designing the systems through which downstream interventions are implemented—ensuring that services and infrastructure are delivered equitably, sustainably and with accountability. For example, workplace safety laws require employers to provide protective equipment for workers, and universal healthcare coverage legislation creates the conditions for primary care, acute care and immunisation programmes to be delivered as public goods rather than discretionary services.^{40 41}

However, the global health job market is fundamentally constructed by the same structural forces that prioritise downstream over upstream solutions. A global health graduate, for example, is far more likely to find employment in organisations focused on service delivery or project-based implementation—roles that engage symptoms—rather than structural forces. While some positions incorporate elements of upstream focus, it is unlikely to make a collective meaningful dent in our progress towards health equity. We encourage students to recognise this asymmetry not as a reason to disengage but as a call to help create new platforms for upstream determination in whichever role they work in. This includes considering leading or being part of social movements, participating in cross-sector alliances and building relationships rooted in mutual respect and equity with communities and partner organisations.^{31 42} After all, addressing upstream determination requires time, sustained effort and collective organisation—conditions best met when graduates see themselves beyond future employees, but as part of broader movements of ‘upstreamists’ working towards systemic transformation.²⁴

Over the years, we have seen many students come to the global health classroom driven by a genuine passion to support communities—whether in the global South or the global North. They arrive eager to undo the unjustifiable magnitude of human suffering, imagining solutions grounded in direct service. As their understanding deepens, many begin to recognise the larger upstream forces at play. This transformation can occur gradually, yet sometimes noticeable within a single semester, as students are introduced to critical theory, systems thinking and historical analysis. This aspiration should be nurtured, not dampened. Yet, as teachers, we also recognise that the professional pathways available to our students are designed by a system that rewards downstream technical skillsets. The early career roles on offer are often embedded in projects that embody the very paradigms students are beginning to question.

As educators, we consider it our duty to ensure that pathways towards equity in global health do not replicate the unjust practices of the past or present.⁴³ Even when students enter roles primarily focused on downstream interventions, we remind them, often in our role as career mentors and supervisors, that these can still be approached with an upstream orientation. Our goal is to equip them to challenge seemingly simple, well-intentioned interventions; engage collaborators with critical awareness; and evaluate when a method may be misaligned with the systemic and structural nature of the problem. This includes promoting peer-to-peer learning networks and communities of practice with fellow ‘upstreamists’ who can support political development.²⁴

We also recognise the constraints that shape our own work as educators—many of us in global health continue to rework and operate within systems that privilege downstream metrics and fundable outputs as a result of external pressures. While many of these projects hold real value, we recognise along with many colleagues globally, that to truly improve health equity, upstream thinking is not optional but a moral and pedagogical imperative.

Conclusion

How we teach matters. If global health is to meaningfully confront the roots of health inequity, we must equip our graduates with the capacity to challenge the status quo—to understand, as the saying goes, that ‘good health begins where we live, work and play’, and therefore to look, think and act upstream. To do this, we cannot rely solely on academic instruction and academics. It calls for a deep engagement with practitioners, activists, policymakers and communities to understand the mechanisms by which those most marginalised may, themselves, move upstream in their own efforts and strategies towards liberation, equity and justice. By listening to communities to understand what they need to lead lives, which they have reason to value, we can use our voice and influence to move upstream alongside them, or at their direction. Crucially, this work demands self-reflection and institutional critique. We must recognise how our practices may contribute to maintaining the status quo, and actively model the upstream orientation we hope our students will carry forward.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.