good evening from los angeles. i'm tavis smiley. tonight as part of our road to health series, first a conversation with dr. rishi manchanda. ma who believes that health, like sickness, begins in the places we live, work, and play. then, academy award winner melissa leo joins us to talk about her starring role in showtime's new series "i'm dying up here. we're grlad you joined us. all of that coming up in just a moment. ♪ ♪

>> and by the robert wood johnson foundation, working with diverse partners to build a national culture of health so everyone can live productive and healthy lives. the california endowment. health happens in neighborhoods. learn more. >> and by contributions to your pbs station from viewers like you. thank you. ♪ >> please welcome dr. rishi manchanda to this program. he's part of a new generation of health care practitioners who

specialize and see health as more than a chemical equation that can be balanced. health begins in the place where is we live, work, eat and play. so i'm pleased to have dr. rishi manchanda on our program as we continue our road to health series. good to have you on. >> thank you so much. >> i've been r reading about yo work. you refer to yourself as an upstreamist. what does that mean? >> the term comes from a parable that i heard early in my career and i adopted and made it my own. three friends come to a river, it's a beautiful scene. unfortunately something tragic happens. there are people in the water, children, adults, the elderly, all drowning. the three friends that come to the river jump in and save those. the first friend says i'm a strong swimmer, i'm going to go to the edge and save those about to drown. the rest of us say that makes sense, rescue those about to drown. the second friend says, let me

swim a little further upstream and i'll coordinate some of the branches and build a raft and usher more people to safety. sometimes the success rate is marginal. they're doing noble, heroic work. but something happens. they get a little fatigued and tired. they start saying things like, didn't someone teach you how to swim to people in the water. and then they realize wait, the third friend, where is she? they look up and she's in the water, saving people, but she's swimming away from them. they say where are you going? she says she's doing the work, and she shouts back, i know, i'm going to find out who or what is throwing these people in the water. and the health care workforce, we have the downstream rescuers, the raft builders, the primary care folks. we've always had the third friend, what i call the upstreamist, that third friend that health care practitioners whose job it is to understand where people live and work and

as importantly, to have us figure out how to translate that knowledge to prevent more people from falling into the water. >> who then is throwing these folk in the water, these people being subjected to unhealthy conditions where they live and work, no access to high quality foods, who is throwing these folk in the watter? >> the who already wahat, the what speaks to what we have all known, the structural causes. the isms. these are historic forces that often define the nature of a neighborhood, and more importantly, what is not sometimes in a neighborhood, the access to the healthy food, the parks, et cetera. it's sometimes who, what political scientists call the social determinenants of health but the political determinants. we now know more than ever discussions in d.c. and state capitals around the allocation

of resources, policy, those have meaningful impacts. in health care, who has access, who doesn't, these are the choices that ultimately define the nature of who falls in the water and who doesn't. >> there's going to be -- it seems to me with all three of those friends, there's money to be made. but the real money is being made by folk who stlthrow them in th water in the first place. as long as there's people suffering, there's money to be made top down. you take my point here. what do we do about people in this because there's money to be made. and if everybody we healthy, you include, would be out of work. >> there's this idyllic vision that motivates a lot of doctors that are in the workforce to say give us the tools and the technologies and skills to learn how to take care of those

downstream. but there are always doctors that say i went into medicine to help people, and that's not just mending people when they're about to fall over the waterfall but preventing it in the first place. to your point, it's a well taken point, who is profiting? it gets to the question why do we have system why we have so many people in the water and not enough upstreamists. unfortunately, it's not just one villain. we have all made choices. >> a network. >> and it's happened over decades. and in some ways it's happened on both sides of the aisle. it's beyond political and ideology. there's been this belief that health care is based on volume, let's pay for volume and not value. that's shifting now. that started happening about ten years ago. the affordable care act, obamacare helped to solidify some of the changes towards value that we're having.

but as this is happening, as everybody has some responsibility, including physicians and hospitals, including communities and policymakers, i know every day in the clinics in los angeles, in cities around the country, we can't afford to wait to define who is responsible. we have to act. because you have too many people coming into the clinics in south l.a. where i used to work, in the v.a. system where i took care of homeless veterans, in clinics up and down california, with colleagues who say, my patients are coming in because of headaches due to mold infestations in their home. give me the tools i need to take care of that, not just prescribe pills. we need to figure out ways to act. that's the upstream approach to health care. >> who cares enough about that reality to do anything about it? this is not a skill challenge, it's a will challenge. we know we have the skill, but

who cares enough to address the problem? >> it's certainly -- about five years ago, 90% of physicians said their patient's social needs were as important as medical problems. the problem is only one in five of those physicians will have any ability to do something about it. they lack the confidence and sense of efficacy. so it's a challenge of will, and how to really not why but how. there's a couple of things that happen that folks like myself who have been talking about the upstream thing are getting some opportunities like this. when you start having people who are paying for health care, what it's individuals, whether it's employers who are aligned but to see the value of what they're doing, and you see public payers like medicare and medicaid and others start saying we should continue to pay for every service. what's happening is, we're

spending 2 1/2 times more than any other nation on health care but we're getting less return on investment. when you have those payers, as has been happening in the past five years, start asking give us value, not just volume and asking the health care system to come to terms with that, it's creating an opportunity where the value conversations are coming into play with the upstream lens, and that's the moment we're in right now. what remains to be seen, and i'm the first person to evangelize and be a skeptic, the challenge we have is this urgency of now is to figure out how to capitalize on this opportunity to demonstrate this approach really works. and i think this is the first time in a generation that we can do that. >> why do you think the timing is now for doing that successfully? >> i think there's a little bit of a tipping point emerging. it has been happening over the past ten years. those folks who are paying the bills are starting to ask for better value. i think it's because of an

awakening culturalry. i think patients, community members are starting to have a voice. whereas before it was doctor knows best. so there's a cultural change inviting people to have a voice. it's also about this moment we're in historically where we're all realizing we're in this together. if you have a part of our economy taking up more than 20 cents of every dollar that we spend, and that's robbing other opportunities to invest in education, to invest this public health and transportation, to invest in girding up the neighborhoods of america, there is this set of questions that i think will be solved in the awakening of the pain out there in many different communities out there that were seriously blind. there was a lot of, i think, eye opening ex-peerpszperienceexper

as they were, during the election process. >> let me turn to your analogy of those three friends in the water. i don't want to get in too much trouble with black folk and their lack of buoyancy when it comes to swimming, but it seems to me that disproportionate number of folk drowning in that water are black and brown. for whatever reason they're unable to swim. so while we hypothesize about this, and talk about how to capitalize about this, and how to address this, you got folk in the water still dying disproportionate to people of color. what are we going to do about that? >> you're exactly right. there's a lot of folks saying we hear about value, and one of the important things to your point is we have to ground this conversation in values and that includes justice and fairness, equity. there's no doubt that as payers

and health care providers try to capitalize on this moment, that we have to be mindful of the lopsided nature of health and illness in america. and the reason for those disparities is because of those policies of racism, structural racism especially, that has long been codified in our nation's policies. that is a direct influence on the distribution in black and brown communities. what is important is to figure out ways to have a conversation about what will we so need is more investment. we are compared to all of our peer nations, the only country that has a lopsided ratio of spending. we spend more on health care than social services. other peer nations, it's the on sid. it's called the american health care paradox. there's no surprize to those who are in communities.

that's why we have these disparities. we're not investing in communities that have been marginalized and continue to be marnl natur marginalized. part of my role as a doctor is to bear witness and figure out how to invite others in to this conversation about changes that need to be made, value based and values driven. and it has to be based in a framework of equity and justice. >> indeed it does. thank you. >> thank you. up next, actress melissa leo. stay with us. >> please welcome oscar winner melissa leo back to this program. she stars in the new showtime series "i'm dying up here," which is based on the l.a. comedy scene in the 1970s. here is now a scene from "i'm dying up here." >> you want to go on "the tonight show?"

>> yes. >> let me help you. find a voice. >> i have a voice -- >> just like our mutual experiences, huh? then i'll put you on the main stage, front and center. >> they're all there on your stage. why is it any different for women this there's room for me, too. >> when you're ready. >> ummm, let me start with confidence. what's great about this project is it doesn't just show the funny side. but it also shows the back story that every comedian i've ever had on this show, if they're being honest, will add mimit, s much of that comedy comes from a dark place, and you do a good job of showing the other side of the lives of these comedians

when they're not up stain. >> i'm dying up here. >> but it's an honest portrayal. >> thank you so much. i think it's -- i think the intention of drama about standup comics. it is -- when you look at their lives and the way that the show does, going home from having a good night at the club can be one of the most depressing things. >> what did you learn about the comedy scene in l.a. back in the day by doing this project? >> oh, golly, i learned so very much. for one thing, we have a bunch of guys on the show. but they were young back in the day, and all the comics that do work on the show have had their own stories that they shared with us along the way. you know, working with the comics have been a terrific part of the show and learning about

that whole world. i had never been inside a comedy club. go, do it. go to a comedy club. it's an amazing experience. and, you know, like at the store here on sunset, they have three different rooms in which to play. so there is a whole lot to be learned. every day on the set with all of them. and about that scene back then and about who missy shore is. i started playing her never having heard of missy shore. now so many people have come up and talked to missy to me. i do feel like i know her now. >> what do you admire about what she was able to do? >> well, by my understanding of it, i kind of grasp that back before our show begins in '73, goldie had done something --

well, missy shore did do this. she was a unique individual, and she had this place that was throughout her husband's venue for whatever they did there, a poetry reading, folk songs, whatever they could draw in people with, and maybe a little funny time here and there. but apparently, at one point, missy is left with the store to herself. she paints the place black, puts a spotlight on the stage and says "only comics." nobody had ever done it before. if you think about any of them, seinfeld or -- they do this thing of standing in a spotlight with a brick wall or a velvet curtain behind them, tiny post stamp of a stage, but without a doubt, the focus is on a funny. that's what missy did, and that's the piece of missy that i bring to goldie, what she did, not who she is. >> what do you make of a woman in that era having the insight,

the commitment and the clout to make that happen for this many comedians whose names now are household names? >> i think she had to pave the road for herself, and that's something i learned in every episode i played of goldie, that she had to fight for the right to have the opinion she had. she had no clout. she gave herself the clout. she said, i will use the one talent i know i have. and that's knowing what funny is. and she doesn't care if you're a guy or girl, black or white, from guatemala or down the road. she knows funny. and she wants the funny in her shop, because that's where she's going to thrive. that's where she's going to get the kind of respect she's looking for. i don't think it's unusual that a woman of her time and age has

the inspiration or the idea. i think what's amazing was that she was able to make it happen. and she doesn't get a lot of thank you for it. >> one of the thank yous, which came time and time again, was when johnny carson would end up having so many of these comedians on his show. and we've kind of gotten away from that. there are a couple of guys tryiying it now, but carson wou put these comedians on all the time. again, across the country, everybody watches johnny carson. unless and until they watch your series, they may not know the back story. so tell me more about that relationship. >> well, that again is something that's really based on facts. carson has got some pretty big stakes going on national television there, long before

computers and the other forms of getting information and finding a way out of your own particular hole up to the top. there weren't very many rows, so to have a successful five minutes on "the johnny carson show" could change lives and did not just once or twice, but again and again. you know, our show depicts something that, by my understanding, did happen, that carson came to rely on this one woman to have the taste of who is going to cut it and who's not. there's a lot of other people who might have put people in front of carson and his bookers that they liked rather than were good. and goldie is not getting involved in that. she's got a reputation that has to do with her taste. so it matters who she is saying is good, right. >> what were those tastes like? >> well, here's the story i think, because of what provided for the back story.

so clearly goldie grew up east coast, in the broadville theater that her parents -- yiddish theater and all at, that her parents were connected to. by the time you get to the '50s and '60s, vaudville is not going to survive. so what is that platform going to be for funny people? you know, there's an argument to be made if, in fact, the store was not invented, maybe we wouldn't even have that kind of standup comic thing. huge today. i mean, it's huge. and that hugeness of it, the time in which our show in the early '70s is when it was really breaking out into something that was -- the world was a different place all those five minutes ago, so the choice is more limited. something really could happen overnight.

>> what do you -- this is a strange question, but because you have been such a great actress for such a long time, you play all kinds of roles in any number of time periods. what's the coolest thing about playing a character in the '70s? >> i guess for me, i get to enjoy the '70s. for me, the '70s, coming of age in the '70s, disco, what is this? >> this ain't going to last. >> nobody is going to remember this nonsense. so it's great to revisit it. and it's even better to revisit with my costume designer. goldie is a hip lady, you know. she knows the time she's in. but she also has not forgotten the time she grew up in. and so to bring a little of that that 40s into the way she looks and the prints and patterns she chooses, that was a real

delight. >> how did the comedians regard her? not the access that she can give them, not the access to carson or other opportunities, but how did they regard her as a person? >> i would say for the most part, the most accurate word would be that word we probably shouldn't say that begins with "b." [ laughter ] but yeah, that is the very interestingly put question, because who she is and what she's doing is one thing. >> yeah, yeah. >> and who she is thought of by the others, she's just one lady all by herself. and there's a bunch of them, and they spent a bunch of time all together, they can talk about her like nobody's business. who does she got to talk to? >> she knew that they had that impression of her. >> i think she didn't care. i think it's mostly she doesn't care. people are going to think what

they think. she's been through enough and seen enough and she has more important agendas than to worry about what people are thinking about her. it's not going to help her. i bet people have been calling goldie names all of her life. >> and she just handles it. >> or ignores it, throws it back. who knows? >> you're an academy award winner, so you don't need much help. [ laughter ] >> i think sometimes they think my comments on their acting are ill-timed. >> we'll leave that right where it is. "i'm dying up here" with melissa leo. good to have you back. >> thank you. >> my pleasure. that's our show tonight. thanks for watching. as always, keep the faith. -- captions by vitac -- www.vitac.com

>> for more information on today's show, go to tavis smiley at pbs.org. >> i'm tavis smiley. join me next time with ricky widdle, about the small screen adaptation of the novel american gods. that's next time. we'll see you then. >> and by the robert wood johnson foundation, working to build a national culture of health so everyone in america

can live productive and healthy lives. the california endowment. health happens in neighborhoods. learn more. >> and by contributions to your pbs station from viewers like you. thank you.

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