Ananya Devadiga

1/19/18
Annotated Source List
1 in 4 Baltimore residents live in a food desert. (2015). Johns Hopkins Bloomberg School
of Public Health. Retrieved from https://www.jhsph.edu/research/centers-and-institutes/
johns-hopkins-center-for-a-livable-future/news-room/News-Releases/2015/1-In-4-
Baltimore-Residents-Live-Food-Desert.html
Summary:
Researchers found that one in four of Baltimore’s residents was living in a food desert.
Neighborhoods located in this area tend to have higher rates of cardiovascular disease, diabetes,
and other diseases related to unhealthy diets. Overall mortality rates are also higher in these
areas. In terms of demographics, researchers found that 34% of African Americans lived in food
deserts, compared to the 8% of white residents. 30% of the school-aged children in Baltimore
lived in these food deserts. Food deserts were defined as areas where residents have to travel
more than ¼ th of a mile to reach a supermarket. The solution is to first provide proper
transportation and healthier options in food stores. Policies and programs are being debated upon
to improve economic development.
Application:
I needed more information on food deserts and this article provides information from Baltimore
itself. It reiterates the lack of transportation and highlights specific statistics. I’ve been finding a
lot of racial differences in terms of who seems to be affected by these upstream factors. I may
consider looking into that and asking Dr. Yousuf questions on any relationship between this that
he has seen.

Bharmal, N., Derose, K. P., Felician, M. & Weden, M. M. (2015). Understanding the
upstream social determinants of health. RAND Corporation. Retrieved from
https://www.rand.org
/content/dam/rand/pubs/working_papers/WR1000/WR1096/RAND_WR1096.pdf
Summary:
Social determinants of health (SDOH) are any non-medical factors that affect health. They also
include upstream factors social disadvantages and inequalities. There are three approaches to
looking at SDOHs: Social disadvantage, life course and health equity approaches. Social
disadvantage approach looks at the link between health and “neighborhood conditions, working
conditions, education, income and wealth, and race/ethnicity and racism.” Life course approach
looks at sensitive periods in a person’s life and its correlation with health. Health equity
approach looks at the link between health and social inequalities that stem from socio-
demographic factors. Looking specifically at the social disadvantage approach, several factors
were listed that affected health. Neighborhood condition influenced health through physical
characteristics, availability and quality of neighborhood services and social relationships within
the community. Physical characteristics included air and water quality and access to parks.
Neighborhood services included transportation and schools. Social relationships included trust
among neighbors. Working conditions influence an individual’s health. The physical aspects of
work could affect the risk of disorders, sedentariness and obesity. Physical conditions at work,
such as ventilation and noise level, psychological aspects, such as stress and rewards, and social
aspects, such as coworker support, have all affected health. The health care benefits provided by
the employer affect the health-related decisions people make. Education links to health in three
ways. Education means better health through an individual’s knowledge on health and healthy
behaviors. Education also provides more and better job opportunities which also affect economic
resources available to a person. Education also influences health through social and
psychological factors such as personal control and social support. Racial residential segregation
produces and perpetrates social disadvantages such as low quality, poor schooling and unsafe
housing. Accumulated stress may also trigger cortisol and other substances that may damage the
immune system, leading to the early-onset of chronic illnesses.
Application:
The specific upstream factors I want to look at are housing conditions, food deserts and
education, most of which were included in this paper. I chose to look at the social disadvantage
approach as it relates directly to my research. The paper also provided some definitions which I
can include in my paper.

Bowman, W. S., Faird, A. & Aronowitz, P. (September 2017). Heartburn or heart attack?
A mimic of MI. Cleveland Clinic Journal of Medicine, 84. Retrieved from
http://www.mdedge.com/ccjm/article/145679/cardiology/heartburn-or-heart-attack-
mimic-mi
Summary:
The journal article discusses how heartburn can be wrongly identified as a heart attack because
of similar symptoms. The article starts by listing the symptoms the patient presented when he
came into the ER. The patient had several heart related issues in the past and had come in due to
sharp pain in his upper stomach and chest. The pain had resolved itself before he had arrived. He
listed some weakness and back pain and had been self treating indigestion with 15 calcium
carbonate pills a day. The cardiology consult was requested because of a concern of a heart
attack. However, the issue was diagnosed as milk-alkali syndrome caused by excessive ingestion
of calcium and alkali. Because of his history of cardiac issues and an abnormal EKG, the first
thought was a heart attack. STEMI and heartburn have similar symptoms and can be
misdiagnosed. It is important to look at other aspects and not just an EKG in diagnosing as
several issues cannot be seen with the reading alone.
Application:
I am just getting started in my research and this was an article that my mentor had given me just
to get a feel for these types of journal articles. If I were to go into specifics about a disease or
misdiagnosis, this would be a very relevant article to use. The data is not biased and presents
data from labs, patient interviews and scans. It also provides references if this is a topic I would
wish to study further.

CNN. (2015, January 28). Link between lack of sleep and obesity [Video file]. Retrieved
from https://www.youtube.com/watch?v=llJsK0pjM2s
Summary:
This video talked about one of the causes of obesity, lack of sleep. Sleep helps with growth,
immunity, heart health, good behavior, and the ability to process information. A study showed
that people who got less sleep had more body weight and a predisposition to being obese than
children who got enough sleep. Lack of sleep affects obesity for many reasons. The longer a
person stays awake, the greater chances that they are eating leading to more calories. Sleeping
also balances hormones that suppress appetite. Not getting enough sleep leads to an increase in
appetite. Eventually, obesity will lead to other problems such as heart disease, diabetes and high
blood pressure. The Dr. Shu recommended that children get the amount of sleep needed for their
age, at least one hour of exercise each day, and eating a healthy diet. CDC recommends 16-18
hours of sleep for newborns, 11-12 hours for preschoolers and at least 10 hours for school-age
kids. Adults should get around 7-8 hours of sleep. Although sleeping is important, it is important
to watch what you are eating as well because no amount of sleep will help if you are not getting
the nutrition they need.
Application:
To go along with the theme of lack of sleep, this video explained how sleep aids in the well
being of a person. It also provides recommendations for hours of sleep people should be getting,
and I can say for a fact that both me and my parents do not get the required amount of sleep.
Many patients who have issues with obesity complain about their sleeping habits as well.

Cooper, L. (2018, January 8). Contact form email from Ananya Devadiga [E-mail].
Summary:
I emailed Dr. Cooper, a public health physician, and a Bloomberg Distinguished Professor at
Johns Hopkins. She provided me with other professionals I can speak with that directly related to
my research since she was not able to talk to me herself. For example, I was given the names
Drs. Pete Miller or Deidra Crews regarding food deserts and Drs. Rachel Thornton and/or Craig
Pollack regarding housing and neighborhood level factors.

Dean, L. (2018, January 10). Contact form email from Ananya Devadiga [E-mail].
Summary:
I emailed Dr. Dean, a social epidemiologist researching how socioeconomic factors contribute to
health disparities and health outcomes for those managing chronic disease. She did not see
herself fit to answer my questions as she does nearly nothing in cardiovascular epidemiology and
as a PhD scientists, doesn’t work with patients at all. She reached out to two doctors who she
thought would be a better fit for me and provided me with a website with contact information for
more professionals.

Dutt, M. (2017). Upstream. Retrieved from http://www.thinkupstream.net/about_upstream

Summary:
This website is written by a company that focuses on upstreaming which is investing in better
health by improving aspects of our life, not just by taking medicine. This includes income,
employment, education, early childhood development, housing, nutrition and the wider
environment. The company has a team of responders that know how to get people the resources
needed when it is found that their housing conditions or external factors are the ones that are
affecting their health. The social determinants are what make the greatest differences to our
health and addressing these issues could solve many preventable diseases. Giving medicines is a
short term fix to a long term problem. The upstreamists focus on the long term issues that affect
patients every day to get to the root of the problem and save patients many trips to clinics or
hospitals.
Application:
The upstream approach is something that has started to interest me as I delve in deeper. This
website contains professionals I could potentially contact for interviews or questions. It also
gives stories and examples I could collect data from in the future.
 Ethnic and racial minorities & socioeconomic class. (n.d.). APA’s Office on Ethnic
Minority Affairs. [Fact Sheet]. Retrieved from
https://www.apa.org/pi/ses/resources/publications/ factsheet-erm.pdf
Summary:
Socioeconomic status (SES) includes income, educational attainment, financial security,
subjective perceptions of social status and social class, quality of life attributes, and the
opportunities and privileges afforded to people within society. SES contributes to both physical
and mental health. In terms of race, research has shown that race and ethnicity often determine a
person’s socioeconomic status. In communities that are segregated by race, common
characteristics include low economic development, poor health conditions, and low levels of
educational attainment. Discrimination and marginalism also affect the lives of racial minorities.
39% of African American children and adolescents are living in poverty. African American
unemployment rates are typically double that of Caucasian Americans. African American men
working full-time earn only 72% of the average earnings of comparable Caucasian men and 85%
of the earnings of Caucasian women. The sheet then looked at the correlation with education.
African Americans and Latinos are more likely to attend high-poverty schools than Asian
Americans and Caucasians. Along with socioeconomic disparities that may deprive students of
valuable resources, high-achieving African American students may be exposed to less rigorous
curriculums, attend schools with fewer resources, and have teachers who expect less of them
academically than they expect of similarly situated Caucasian students. 12.4% of African
American college graduates between the ages of 22 and 27 were unemployed in 2013, which is
more than double the rate of unemployment among all college graduates in the same age range.
Application:
This fact sheet also provided stats that I can use to defend my claims. It provided correlation
between race, education and both physical and psychological health.

Finley, R. (2013, March 6). A guerilla gardener in South Central LA. [Video file].
Retrieved from https://www.youtube.com/watch?v=EzZzZ_qpZ4w

Summary:
The Ted Talk is by Ron Finley, a common man in South Central LA. He lived in an area where
fast food, liquor stores and vacant lots were frequent. He also lives in a food desert, a place
where the nearest grocery market with fresh foods is about a 45 min drive. He says that South
LA is “home of the drive through and the drive by,” which is killing people. Obesity rates are
high because of the lack of proper nutrients, wheelchairs were bought more than used cars, and
dialysis centers were popping up everywhere. So Mr. Finley decided to do something about it
and planted a food forest in front of his house. The land was owned by the city and he got cited
for his garden. However, news reporters did stories on his work and soon councilmen started
endorsing his project. He says that, “growing your own food is like printing your own money.”
He gave this food out to needy families, purposely growing it out in the streets so it’s accessible
to everyone. He also talks about teaching kids on how to be self-sufficient, gardening their own
food, knowing how to maintain their health. His plan is to get everyone to grow their own food
and sell it, to make it sustainable.
Application:
One of the topics that Dr. Yousuf was explaining to me was the psychological and background
aspects of people’s lives that affect their health. This includes their living conditions and family
status. He had referenced this Ted Talk to me because it shows how something as simple as
growing your own food could help drop obesity rates, which leads to cardiovascular issues.

Health disparities experienced by black or African Americans --- United States. (January
2005). Centers for Disease Control and Prevention. Retrieved from
https://www.cdc.gov/mmwr/ preview/mmwrhtml/mm5401a1.htm
Summary:
This article listed mainly statistics that one can use to make inferences. 12.9% of the U.S.
population, identified themselves as Black or African American. For many health issues, risks
factors are greater for blacks than whites. Non-Hispanic blacks who died from HIV disease had
approximately 11 times as many years of potential life lost before age 75 years per 100,000
population as non-Hispanic whites. Non-Hispanic blacks also had substantially more years of
potential life lost than non-Hispanic whites for homicide (nine times as many), stroke (three
times as many), perinatal diseases (three times as many), and diabetes (three times as many). The
age adjusted incidence for cancer and strokes is substantially higher for blacks than for whites.
The census also looked at indicators of progress towards national health objectives. Blacks were
behind whites in at least four positive health indicators, including percentages of persons aged
<65 years with health insurance, adults aged >65 years vaccinated against influenza and
pneumococcal disease, women receiving prenatal care in the first trimester , and persons aged
>18 years who participated in regular moderate physical activity . Blacks also had higher
proportions of certain negative health indicators than whites, including new cases of gonorrhea,
deaths from homicide, persons aged 6--19 years who were overweight or obese, and adults who
were obese. The article ended by saying multiple factors contribute to racial/ethnic health
disparities, including socioeconomic factors, lifestyle behaviors, social environment, and access
to preventive health-care services.
Application:
I have decided to look into how upstream factors affect African Americans. Although this
provides a comparison between whites and blacks, I can use the stats as evidence to back up my
research. This is, however, from data in 2005. I will try to find more current stats.

Heart disease. (2017). Retrieved from https://www.mayoclinic.org/diseases-conditions

/heart-disease/symptoms-causes/syc-20353118
Summary:
The term “heart disease” encompasses a broad range of topics such as blood vessel diseases,
heart rhythm issues and heart defects. It is often used synonymously with cardiovascular disease.
Symptoms of heart disease may include chest discomfort, shortness of breath, and pain in several
areas of the body. There are also specific symptoms to each individual typeof heart disease. The
article then talks about how the heart works. There heart is split into the right and left sides and
four chambers. Oxygen poor blood enters the right side and oxygen rich blood enters the left side
and leaves to go to the rest of the body. The four valves of the heart keep blood from flowing
back into the chambers. Electrical impulses sends signals to the heart to pump blood. Plaque
buildup, heart defects, high blood pressure, diabetes, smoking, excessive use of alcohol or
caffeine, drug abuse and stress are all possible causes of heart disease. There are also several risk
factors that could increase the chances of getting heart disease. Age, smoking, cholesterol levels,
diet, blood pressure, diabetes, obesity, and poor hygiene can all add to cardiovascular issues. The
website had several prevention methods as well. Quit smoking, controlling health conditions,
exercising, healthy weight and reducing stress are all ways to prevent heart disease.
Application:
Although the article doesn’t mention the word upstream, many of the risk factors and causes
listed are all upstream issues, things that are related to where someone lives and the kind of
lifestyle a person lives.

High blood pressure (hypertension). Mayo Clinic. Retrieved from

https://www.mayoclinic.org /diseases-conditions/high-blood-pressure/symptoms-
causes/syc-20373410
Summary:
Hypertension is a condition in which the long-term force of blood against arteries leads to other
health issues. Blood pressure is determined by the amount of blood your heart pumps and the
amount of resistance to blood flow in your arteries. The more blood your heart pumps and the
narrower your arteries, the higher your blood pressure. High blood pressure may be
asymptomatic for several years but may cause progressive damage. Blood pressure is taken at
check ups and is high blood pressure is easily and usually detected. Primary hypertension has no
specific cause and usually is gradual. Secondary hypertension has an inherent cause such as sleep
apnea, thyroid problems, congenital blood defects, etc. Risk factors include age, race, family
history, obesity, limited physical exercise, use of tobacco, salt intake, low potassium, low
Vitamin D, alcohol consumption, and stress. Hypertension could eventually lead to heart attack,
stroke, heart failure, aneurysm, weakened blood vessels to kidneys or eyes, metabolic syndrome,
or memory issues.
Application:
I realized during my presentation that I didn’t have sources on hypertension even though I
mentioned it in my presentation. I figured I should probably find some information on it so I can
use it in my paper, and so that I can be more informed on what I’m talking about even though it
isn’t evidence to support my claim.

Holguin, J. (2004, January 5). Fast food linked to child obesity. Retrieved September 24,
2015, from CBS News website: http://www.cbsnews.com/news/fast-food-linked-to-child -
obesity/
Summary:
In a study done on 4-19 year olds, almost one-third of the youngsters eat fast food which adds up
to 6 extra pounds per year per child. The results were reported as not surprising as many fast
food companies advertise to children and adolescents. The highest levels of consumption were
found among boys, youngsters in households with higher levels of income, older children, blacks
and children living in the South. The lowest levels of consumption were found among youngsters
in the west, rural areas and Hispanics. Children who eat more fast food tend to eat more
carbohydrates, sugars and fats rather than fruits and vegetables. The study did not mention the
children’s weight. Children’s levels of fast food intake are much higher because of the growing
amount of fast food chains. However, many chains have included healthier options in their menu.
Recent data shows that 15% of children are obese. This study contradicts a previous study that
concluded that fast food chains were not the main culprit of obesity.
Application:
I needed more evidence on food deserts and links to obesity, so I found this from previous
research I had done and it relates to my current topic. Food deserts lead to food being bought
from convenience stores and fast food places which leads to obesity. Although this focuses on
children, it can be generalized to the general population.

Illegal drugs and heart disease. (2017). Retrieved from http://www.heart.org/HEARTOR

G/Conditions/More/MyHeartandStrokeNews/Illegal-Drugs-and-Heart-
Disease_UCM_428537_Article.jsp#.WfvVBmhSxPY
Summary:
The article was about drug usage and its effect on cardiovascular issues. These issues could
range from fast heart rates to heart attacks to infected valves and arteries. Drugs can also affect
the nervous system, creating symptoms such as changes in body temperature, heart rate and
blood pressure, headaches, body pains, heart attacks and respiratory attacks. Cocaine users have
thicker heart muscle walls, stiffer arteries and higher blood pressure than non-users which
increases their risk of heart attacks. It is the one of the most prevalent drug in the United States
and has increased. It is also the most common in form of drug abuse that would be found in a
hospital’s emergency room. Along with cocaine are amphetamines and ecstasy which do the
same damage as cocaine and have the same effects on the cardiovascular system.
Application:
Cocaine and heroin were the most common drugs in the St. Agnes emergency room as well. The
patient would have taken some drugs in the morning and then they would come to the hospital
because their BP was high or their heart rate was high and all the hospital can do is detox and try
to get him to stop using the drugs. If the patient uses drugs, it’s obvious that he or she is going to
have some sort of issue in their body. Getting rid of the habit would be an upstream effect and is
so relevant in Baltimore especially.

J. Harrison, personal communication, October 24, 2017

Summary:
Jessica Harrison is a preventive cardiology nurse who works at the congestive heart failure clinic
and cardiac rehabilitation center at St. Agnes Hospital. As a preventive nurse, her main job is to
teach patients about their disease and how to treat or keep them out of the hospital. She
mentioned that this was a very important aspect of health care as patients have to meet doctors
halfway in treatment. Ms. Harrison said that she has to be very nosy with patients to find out all
the factors in their life like their living conditions and family issues that could be contributing to
their health issues. With this knowledge she is able to get the patients the resources they need to
stay out of the hospital, such as transportation to appointments, making appointments,
medication and social worker help with living conditions. Specifically in Baltimore, there is a
food desert which means there are a limited number of stores that sell fresh produce and
nutritious food in the area. She mentioned that she lives in Carrol County and it takes her about
15 minutes to get to the closest grocery store but she has the transportation to get there whereas
in Baltimore, that is not the case. She advertises programs such as “Meals on Wheels” to help
patients get the nutrients they need.
Application:
Talking to Ms. Harrison really solidified my thoughts and ideas on my research and opened up a
lot of opportunities to get information. Her expertise in specifically preventive cardiology, which
is what I’m looking into, will help me with any questions I have. The information she has given
me so far has narrowed down the broad term of upstream factors for me.

Kefalides, P. T. & Caley, C. F. (2008). Substance abuse. In The New Book of Popular
Science. (pp. 369-379).
Summary:
This encyclopedia entry was about general substance abuse. A substance abuser is someone who
establishes a pattern of use and continues usage when problems arise because of the drug use.
The user may also take the drug in dangerous situations such as while driving. As he or she
becomes dependent on the drug, they will need higher doses to feel the same “high” as the first
use, which is called tolerance. Without it, they will suffer withdrawal symptoms, demonstrating
the physical dependence of the body on the drug. They may also show psychological motivation
for the drug, planning on how to get their next dose and losing control when near the drug. Risk
factors include, gender, age, age when first introduced to drug, usage of close friends or family,
low self-esteem, disrespect for social values, family problems, feelings of isolation, and personal
characteristics. Genetics may also play a role as some people feel a higher degree of pleasure
which could be linked to a slightly different makeup of their brain. The entry then talks about the
different types of substances. Nicotine is a stimulant found in tobacco. Smoking mainly damages
the heart, blood vessels and lungs. It affects the part of the brain associated with the reward
system. Alcohol is a depressant that depresses the brain’s ability of self-control, which could lead
to dangerous behavior. Hallucinogens include marijuana and hashish which contain THC, PCP
and LSD. Marijuana is the most readily available, affecting muscle control and coordination.
PCP is very dangerous in that it creates hallucinations and may even lead to schizophrenia. LSD
is similar to PCP in that it distorts reality and users see flashes of color and sounds. Stimulants
include cocaine and amphetamines. These drugs speed up heart rate and raise blood pressure and
lead to a sense of euphoria. Depressants include opiates such as opium, morphine and heroin.
The main threats from substance abuse are cardiovascular disease, lung disease and cancer. The
tar in cigarettes is toxic to arteries, narrowing the artery to create clots which increases the risk of
heart attacks and stroke. Therapy for addiction includes detox and treat withdrawal symptoms.
Some may require hospitalization. Rehabilitation focuses on getting rid of the habit through use
of withdrawal tactics like medicine and counseling.
Application:
At my internship, a majority of patients who come into the ER are drug users who were sent to
the hospital when they went to a methadone clinic or a similar facility and it was seen that their
blood pressure was high or their heart rate was high or something like that. I had read a lot of
articles on heart issues, but substance abuse is also a big part of societal factors because of the
community surrounding the hospital.

K. Yousuf, personal communication, December 23, 2017

Summary:
I interviewed my mentor, Dr. Yousuf. He explained how people that have poor housing
conditions have environmental stressors or how you have to have a working refrigerator to have
certain medications such as insulin, so people who don’t have some of these regular amenities
are impacted. For food deserts, if you don’t have access to fresh produce or fresh foods, then you
can’t eat the healthy diet that’s prescribed that goes along with a lot of disease processes such as
heart disease, high blood pressure, diabetes. Often times patients are given very specific diets of
low salt diet or eating less red meat, eating certain types of fruits and vegetables, high fiber diets,
and these are very difficult to find in some urban areas. For education, he talked about health
care literacy and how they don’t understand simple aspects of health or what others may take for
granted such as a simple thing as you need to eat better to be healthier, or you need to be more
active to be healthier. He explained how hypertension was a common disease found in African
Americans. In terms of discrimination, he described institutional discrimination vs systematic
discrimination. By virtue of living in Baltimore City, you have less access to certain things that
we take for granted such as parks in Howard County or open space which has actually been
attributed to health as well so you have open spaces and parks, it is supposed to be good for your
health. He then talked about ways upstream policies had been adopted in the community. There
is much more of an emphasis on trying to find these factors as opposed to just directly dealing
with the disease process or just treating hypertension than before. So we focus more on finding
reasons why people are not able to take their medications such as transportation or access to
medication or just health care literacy and giving them a basic understanding of what it is to
have a certain disease process and then how do you take care of yourself and the importance of
taking medications and or why are the medications important so all of these sort of basic things
that come. He included support systems as an important upstream factor as well. There have
been many studies that look at the importance of people who have more social interactions and
support structures in place, do much better from a health perspective than those individuals that
do not. Often times, things that go hand in hand with poor housing, or low education or
socioeconomic class is the lack of a support structure or lack of social interactions that are
positive and then help individuals with their health.
Application:
Dr. Yousuf filled in a lot of details that I needed to write my outline. He also provided me with
more topics to research and connect for my thesis and supporting paragraphs.

Manchanda, R. (2014, September 15). What makes us get sick? Look upstream. [Video
file]. Retrieved from https://www.youtube.com/watch?v=dJEwC4wCM70&t=41s
Summary:
This Ted Talk surrounds the idea of improving health where it begins which is where we spend
most of our lives outside the four walls of the examination room. Rishi Manchanda, the speaker,
gave the example of a patient named Veronica with chronic headache. She visited the emergency
room 3 times in one week, yet they couldn’t find anything wrong with her. She then came to Dr.
Manchanda’s clinic where a medical assistant first saw her and one of the first things he asked
was about where she lives and her housing conditions. Veronica mentioned that she has roaches,
water leakages and mold in her house. Dr. Manchanda saw her and was able to diagnose her
issue as chronic allergies because of where she lives. His treatment was medications and he
referred her to a community health worker to fix her house that causes her symptoms. When she
returned for her follow up, her symptoms had improved because of the improvement of her home
conditions. Dr. Manchanda then began to explain how we need a system where we ask about
conditions in the patient’s community, an upstream approach. The healthcare system is missing
the upstreamist who knows that health begins where we work and play. We also need a system to
connect to resources outside the clinic. This has more effect on a patient’s well-being than pills
and procedures and causes 60% of preventable deaths. For example, people who live closer to
parks tend to have a less chance of heart disease. He mentioned that a zip code is more important
than genetic code. In health care, we pay for number of services, not how healthy they make you.
The “Don’t ask, don’t tell” phenomenon is that medical professionals don’t know what to do if
there is a problem with your house so they simply don’t ask. There is a gap between knowing
and doing something about it. Then there’s the question of Who’s responsible to do this? And the
truth is that there are not enough upstreamists who know how to put in a system and give
resources. Dr. Manchanda has started a program called Health Begins to train upstreamists and
changing the confidence of health care professionals, so that clinicians have the ability to address
problems of living and working conditions.
Application:
As I learn more and more about the effects outside of the medical office, I feel more confident
that I am going to do my research on it. I could create some sort of presentation to health care
professionals on how to have a more upstreamist approach when dealing with conditions,
especially cardiac issues.

Pascal, C. (2017, December 26). Contact form email from Ananya Devadiga [E-mail].
Summary:
I emailed Dr. Pascal, a Canadian educator, specializing in the positive social, emotional and
cognitive benefits of early child education. He provided me with two resources, the website for
the World Health Organization and an article by Sir Michael Marmot concerning health policies.

Profile: Black/African Americans. (2015). U.S. Department of Health and Human

Services Office of Minority Health. Retrieved from
https://www.minorityhealth.hhs.gov/omh/ browse.aspx?lvl=3&lvlid=61
Summary:
This is a summary of parts of the 2015 U.S. Census. It listed the ten states with the largest black
population and Maryland was on this list. In terms of education, a lower percentage of blacks had
earned at least a high school diploma as compared to whites. Only 20.2% of blacks have a
bachelor’s degree or higher, compared to the 34.2% of whites. More black women than black
men had earned at least a bachelor's degree (22.4 percent compared with 17.7 percent), while
among whites, a higher proportion of men than women had earned at least a bachelor's degree
(34.4 percent and 34.0 percent, respectively). In terms of economics, the average black
household median income was $36,515 in comparison to $61,394 for white households. 25.4
percent of blacks in comparison to 10.4 percent of non-Hispanic whites were living at the
poverty level. For 2015, the unemployment rate for blacks was twice that for non-Hispanic
whites (11.4 percent and 5.0 percent, respectively). For insurance coverage, 75.8% of whites
used private health insurance while only 54.4% of blacks used it. The death rate for African
Americans was generally higher than whites for heart diseases, stroke, cancer, asthma, influenza
and pneumonia, diabetes, HIV/AIDS, and homicide.
Application:
This census provided me with some statistics to cite in my paper. Dr. Yousuf emphasized health
insurance when talking about this subject and this source provided me with that information. It
also gave me unemployment rates, household income and education which relate to the upstream
factors I am looking into. This is, however, for 2015. I will need to find a more updated version
for more information.
 Smith, E. R. (2010). Prevention of cardiovascular risk factors: Moving upstream. The
Canadian Journal of Cardiology, 26(Suppl C), 7C.
Summary:
This article talks about how prevention is becoming a much more emphasized aspect of health
care. It is important to look at not only the causes of the disease but also the “causes of the
causes.” These are mostly socioeconomic factors, but traditional aspects as well such as habits of
a nation as a whole, etc. The symposium at which this journal was presented at was centered
around this topic of preventing the development of risk factors. The organizer and leader of the
symposium wrote a paper outlining the importance of upstream factors. In this, she wrote that
socioeconomic factors not only “influence disease prevalence and incidence, but also contribute
to a treatment gap.” Public policy changes could help prevent risk factors that cause the diseases
in the first place. Subsequent articles went over specific diseases such as hypertension and
obesity and the role of upstream factors on each. The last article talked about the effect of poor
nutrition on cardiovascular disease and methods of intervention. The main gist of the symposium
and articles were that there are upstream factors that, if fixed, could potentially stop prevent the
causes of disease. The main method proposed in the articles was public policy and intervention,
bringing the focus more to these issues.
Application:
This article was basically what I want to do with my research. It lists some factors that I can use
to narrow which factors I want to look at specifically and lists the coinciding cardiovascular
issues that are affected. Obesity was also mentioned which relates to my research in independent
research so that’s interesting for me to look into.

Taheri, S., Lin, L., Austin, D., Young, T., & Mignot, E. (2004). Short sleep duration is
associated with reduced leptin, elevated ghrelin, and increased body mass index. PLos
Medicine. http://dx.doi.org/10.1371/journal.pmed.0010062
Summary:
This study looked at the correlation between short sleep durations and high BMI by tracking two
hormones, leptin and ghrelin. Leptin is a hormone that suppresses appetite and ghrelin is a
hormone that stimulates appetite. The researchers used a method called nocturnal
polysomnography and then blood tests were taken to find the levels of leptin and ghrelin. Several
additional factors were taken into considerations to make sure other variables were not affecting
the results. The results were that participants with short sleeping habits tended to have a low
level of leptin and elevated ghrelin. This could result in an increase in appetite and could give the
reason as to why short sleeping habits are associated with high BMI and eventually to obesity.
Application:
Dr. Yousuf had explained that housing was a big upstream issue associated with health risks. I
dug a little deeper to say how not having proper housing could lead to not being able to sleep or
not getting the required hours of sleep which could eventually lead to cardiovascular issues.
Obesity was a big one I saw when I intern and one of the follow up questions Dr. Yousuf asks is
about their sleeping habits.

Upstream causes and downstream effects. (18 November, 2014). [Web blog]. Retrieved
from https://epidemiological.net/2014/11/18/upstream-causes-and-downstream-effects/
Summary:
This blog post was written by a student studying for a public health degree. He was sitting
through a lecture about health insurance and the assignment was to write about how things and
policies located “upstream” affected groups and individuals located “downstream.” The speaker,
a sociology professor at Hopkins had written a book why women chose to be mothers in light of
being poor and disadvantaged. In reality, these women see motherhood as inevitability. They
believe that being a mother will bring them together regardless of how much money and
resources they have. However, when women were given the opportunity to pursue education,
they chose to get pregnant later. Education, better jobs, and better opportunities located upstream
incentivize women to wait a little bit longer to be mothers. Another example is that tobacco tax
has resulted in less smoking related deaths. It also goes the other way where the story or
experience of one person leads to a change at a societal level.
Application:
This is another example of how public policy can shape someone’s life. Upstream issues can
cause issues downstream and changing small factors can drastically change a person’s well being
or way of life. Although this isn’t specific to cardiovascular issues, it gives a general perspective
to upstream issues as well as a book I could reference.

What are the risk factors for heart disease? (2017). Retrieved from
https://www.nhlbi.nih.gov/ health/educational/hearttruth/lower-risk/risk-factors.htm
Summary:
This article talks about the risk factors of heart disease. This includes high blood pressure, high
blood cholesterol, diabetes, smoking, Being overweight or obese, being physically inactive,
having a family history of early heart disease, unhealthy diet, and age (55 or older for women).
Obviously, some of these risk factors cannot be changed such as age and family history. For
women, menopause increases chances of heart disease because of the lack of estrogen. Also,
someone whose parent or sibling had heart issues is more likely to have heart conditions than
someone who does not have cardiovascular issues in their family. Having even one of the risk
factors is a big deal and with more than one, the risk factors tend to “gang up” on the body,
increasing the chance of heart failure. Making one step in the right direction makes a difference.
Application:
Again, I am just trying to get basic information on my topic. This was a general article on risk
factors, most of which is common sense or known knowledge. These are the more medical
aspects of risks, but I am focusing more on the living and behavioral conditions so I just wanted
a solid background before I start digging into the different aspects.

What is cardiovascular disease? (2017). Retrieved from

http://www.heart.org/HEARTORG /Support/What-is-Cardiovascular-
Disease_UCM_301852_Article.jsp#.Wd7ZmmhSxPY
Summary:
This article gives an overview of heart issues, starting with atherosclerosis, the build-up of
plaque on arterial walls. Because the blood is not able to flow as easily through the arteries, the
heart has to work even harder to get the blood to reach all the parts of the body. If blood flow is
stopped, it causes a heart attack or stroke. Ischemic stroke occurs when blood supply to the brain
gets cut off which results in brain damage. The result is usually inability to speak or walk.
Hemorrhagic stroke is when a blood vessel in the brain bursts, which is usually an issue with
blood pressure. Some effects of stroke are irreversible because of the brain damage. Some brain
cells don’t die, and can regenerate after rehabilitation. Other heart issues include heart failure,
arrhythmia, and heart valve problems. In heart failure, the heart isn’t pumping as much blood as
it needs to. Arrhythmia is an abnormal beating of the heart, too slow, too fast or irregular. Heart
valve problems could mean that the heart valve doesn’t open enough to get the proper amount of
blood through the heart.
Application:
I just wanted a basis to what I cardiovascular issues I am looking at. This site provided generic
information on the issues, the causes and effects as well as a definition. This way, I know what I
am researching when I look at upstream causes that could potentially affect these issues.