The upstream–downstream tension in the global health classroom

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.