Upstream: How to solve problems before they happen

by Dan Heath

Before you can recover, you hear another child cry for help.

“I’m going upstream to tackle the guy who’s throwing all these kids in the water.”

When you spend years responding to problems, you can sometimes overlook the fact that you could be preventing them.

Downstream actions react to problems once they’ve occurred. Upstream efforts aim to prevent those problems from happening.

The specialization inherent to organizations creates great efficiencies. But it also deters efforts to integrate in new, advantageous ways. In upstream ways.

That’s one reason why we tend to favor reaction: Because it’s more tangible. Downstream work is easier to see. Easier to measure. There is a maddening ambiguity about upstream efforts.

A telltale sign of upstream work is that it involves systems thinking:

The psychologist and child development expert Richard Tremblay argues that the best time to prevent aggressive behavior is when the criminal is still in his mother’s tummy.

Downstream efforts are narrow and fast and tangible. Upstream efforts are broader, slower, and hazier—but when they work, they really work.

The point is that our attention is grossly asymmetrical. We’re so focused on saving the drowning kids in the river that we fail to investigate why they need saving at all.

The US health care system is designed almost exclusively for reaction. It functions like a giant Undo button. Blocked artery? We’ll unclog it. Broken hip? We’ll replace it. Impaired vision? We’ll correct it. If all goes well, you will be restored to your baseline health.

Across the political spectrum, we think the best way to “buy health” is to invest two-thirds of our money into systems that make people healthy (food, housing, etc.) and one-third into systems that heal sick people.

In the US, for every $1 spent downstream, we spend roughly $1 upstream.

As Bradley and Taylor point out in a book called The American Health Care Paradox, what’s really distinctive about the US approach to health isn’t so much the quantity of spending but the way we spend it. Compared to other countries, we spend more money fixing people’s ailments and less keeping them healthy. We’re downstream; other countries are upstream.

Where the US health system excels, as a result of this downstream focus, is in treating patients with serious diseases such as cancer or heart disease. That’s why Saudi princes fly to Houston or Boston to have their cancer treated.

These are the fruits of investing in downstream action.

But Norway’s spending priorities are radically different than ours: For every $1 spent downstream, they spend roughly $2.50 upstream.

What do Norway’s different priorities buy? Take childbirth as an example. A pregnant Norwegian woman will pay nothing for all prenatal visits.

Which country’s population is healthier: Norway or the US? It’s not a close call: In infant mortality, Norway has the 5th best results internationally; the US is 34th.

Life expectancy: Norway is 5th, the US 29th.

We can—and we should—stop dealing with the symptoms of problems, again and again, and start fixing them.

Most of us would agree that “an ounce of prevention is better than a pound of cure,” but our actions don’t match those words.

But we’re capable of greater things: less Undo and more Outdo.

Elliott later founded a sports science firm called P3, which assesses and trains elite athletes. The firm uses 3-D motion capture technology to micro-analyze athletes while they run, jump, and pivot.

That puts your relative rotation at the 96th percentile of the athletes we’ve examined, and every single athlete we’ve seen above the 95th percentile has suffered a knee injury within two years. So we should work on that, and after we train it, we are going to reassess it to see how much it has changed. More than half of the current players in the NBA have been analyzed by P3.

“Instead, you look for the signal that there’s a risk there, and then you act on it.

Pro athletes play hard. Injuries are gonna happen. You can’t change that. That mind-set is an example of what I’ll call “problem blindness”—the belief that negative outcomes are natural or inevitable.

When we don’t see a problem, we can’t solve it. And that blindness can create passivity even in the face of enormous harm.

In 1998, the graduation rate in the Chicago Public Schools (CPS) was 52.4%.

That’s just how it is—so no one questions it. That’s problem blindness.

Within CPS, many people had come to accept the high dropout rate.

What the researchers had discovered was that there is something peculiar about a student’s achievement specifically in the ninth grade that predisposes them to succeed or fail in high school.

Elementary schools run from grades K to 8, and high schools start in 9th grade.

“People are vulnerable during transitions,” said Sarah Duncan, whose nonprofit the Network for College Success played a critical role in the CPS work.

For one thing, if ninth grade is the critical transition point, then you’ll want your best teachers teaching freshmen.

Also, seen through the lens of the FOT metric, certain discipline policies began to look self-destructive. “When we started this work, kids got suspended for two weeks all the time,” said Sarah Duncan.

Every system is perfectly designed to get the results it gets. The most profound change, though, was to the mind-set of teachers.

The Freshman On-Track work “changes the nature of how teachers see their jobs.

“It’s the difference from ‘I put the work out there and I assign the grades’ to ‘My job is to make sure all students are succeeding in my class.

As a teacher, if you accept that your job is to support students, not appraise them, it changes everything. It changes the way you collaborate.

Traditionally, teachers would meet by department—the social studies teachers would meet together, and the English teachers, and so on.

But now teachers began to meet across disciplines in what were called Freshman Success Teams.

Every student needs something different.

(Managing attendance is one of the most important parts of the FOT effort—as Ponder put it, “It’s so obvious that if you get through school, you will get through school.”

A ballpark estimate is that between 2008 and 2018 an additional 30,000 students earned a diploma who, in the absence of the CPS effort, would likely have dropped out.

To succeed upstream, leaders must: detect problems early, target leverage points in complex systems, find reliable ways to measure success, pioneer new ways of working together, and embed their successes into systems to give them permanence.

“inattentional blindness,” a phenomenon in which our careful attention to one task leads us to miss important information that’s unrelated to that task.

When it’s coupled with time pressure, it can create a lack of curiosity. I’ve got to stay focused on what I’m doing.

To reinforce that last point about attaining “normalcy,” consider that habituation is frequently used as a therapy for people’s phobias.

But habituation cuts both ways: Imagine instead that what’s being normalized is corruption or abuse.