Upstream: How to solve problems before they happen

by Dan Heath

Dunne saw that the only way to prevent murder was to unite these groups and to direct their focus toward the women at greatest risk.fn1

Based on the patterns in the data, Campbell developed a “Danger Assessment” tool, which has been validated multiple times as an accurate predictor of intimate partner homicide.

The high-risk team of 13 to 15 people met once a month to review the cases of women who had scored the highest on Campbell’s Danger Assessment.

It’s hard to overstate how uncommon—and unlikely—this collaboration was.

In their meetings, the high-risk team would review cases, one by one.

The lesson of the high-risk team’s success seems to be: Surround the problem with the right people; give them early notice of that problem; and align their efforts toward preventing specific instances of that problem.

McCannon believes that groups do their best work when they are given a clear, compelling aim and a useful, real-time stream of data to measure their progress, and then … left alone.

And then the group is basically locked in a room together, armed with regularly updated data to see if the number of calls is going up or down.

But sometimes grounding an effort in concrete data is the only way to unlock the solution to a major problem.

“The very first step is to believe you can actually do it,” said Jaeger.

In the aftermath of the HUD training, the team in Rockford made three critical shifts en route to ending veteran homelessness: a shift in strategy, a shift in collaboration, and a shift in data.

Along with the “housing first” strategy came a shift in collaboration, involving what’s known as “coordinated entry.”

“Data takes you away from philosophical insights. You move away from anecdotal fights about what people think is happening to what is happening,” she said. “You can’t solve a dynamic problem with static data.”

Simply by changing the way they collaborated, and the goals that guided their collaboration, their efforts became dramatically more effective.

They’re moving further upstream: Rather than acting quickly to serve people who are homeless, they’re trying to keep people in their homes to begin with.

As the analogy to Sweden and Afghanistan suggests, a 15- to 20-year gap in life expectancy is massive. You can’t account for it with a few incremental factors. It takes huge, systemic forces to produce a disparity like that.

There’s a well-established link between chronic stress and a variety of health problems, among them cardiovascular disease, diabetes, and inflammation.

The problem was not the lack of treatment. It was the lack of health. Remember: “Every system is perfectly designed to get the results it gets.”

The odds were tilted so far against the people in certain neighborhoods that they couldn’t win.

Systems are machines that determine probabilities.

When we marvel at the inner-city kid who gets into Harvard, we’re marveling at the odds she defied.

Upstream work is about reducing the probability that problems will happen, and for that reason, the work must culminate in systems change.

For decades, tiny amounts of fluoride have been added to community water supplies as a way to protect people’s teeth against cavities. It’s an invisible program—when’s the last time you thought about fluoride in your water?—yet its impact has been enormous. More than 200 million people in the US have access to fluoridated water, and the program has been so successful that the CDC named it 1 of the 10 greatest public health achievements in the twentieth century.

A well-designed system is the best upstream intervention.

Fifty years later—thanks to fewer drunk drivers and better roadways and seat belts and airbags and better braking technologies—that number has declined to about 1 death per 100 million miles driven.

In the meantime, there are countless tweaks being made every week to help fallible human drivers.

On sharp curves where accidents tend to happen, transportation departments have begun to install high friction surface treatments (HFSTs)—overlays of ultra-rough material superglued to existing roads.

None of those drivers, who avoided crashes they would have suffered in an alternate world, will ever know that they may owe their lives to some construction workers who installed a super-gritty road.

The same logic can be applied to business, of course—problems can sometimes be solved with minor changes to the environment.

What’s the “water” you’re not seeing in your home life or at work? What’s interesting is that our kids can often see the water.

My friend told me about watching his baby daughter hunched over a pack of playing cards, running her index finger back and forth and poking it. He was confused until he realized: She’s mimicking me on my phone.

No child should have to hit the green zeroes on a roulette wheel to succeed in life. A fair and just society is built on fair and just systems.

One of the programs supported by the foundation offered financial coaching to low-income people.

Everyone in this whole ecosystem got paid—except for the low-income people. They got coached.

In some ways, the program actually entrenched the very inequalities that spawned it, by creating wonderful job opportunities for well-intentioned and well-educated leaders, but none for the people it was meant to serve.

DonorsChoose is a website that allows teachers to seek crowdfunding for supplies, computers, books, or other classroom materials.

DonorsChoose is a crutch for a broken and underfunded education system. And crutches are vital. They are also supposed to be temporary.

Part of every social-sector organization’s mission should be to push upstream. To prevent wounds as well as bandage them; to eliminate injustices as well as assisting those who suffered them.

We’re casting our net for employees in a pond that’s shallower than we think. Or we’re valuing certain kinds of credentials that limit our pool of applicants while not contributing much to job performance. Or we’re filtering out candidates because of biases that we’re not even aware of.

Maybe we shouldn’t recruit only at those same 10 college campuses. Maybe we should disguise the names and genders on the resumes we consider. Maybe we should train our leaders how to conduct better interviews, so that the conversations don’t degenerate into small talk.

Success comes when the right things happen by default—not because of individual passion or heroism.

No, their vision was to start with power: showing the citizens in these neighborhoods how to fight for themselves and to reshape their environments.

You have an enormous amount of individual power and collective power …. Meaningful participation in democratic processes allows you to express agency, and agency is good for your health.”

BHC’s theory of change is that, if you empower people to fight for their interests, they will win policy victories—they will change the system—which will allow them to transform their environment, piece by piece, shifting the odds back in their favor.

“The community said, ‘No, that money is supposed to go to the most polluted and disenfranchised communities. You can’t take all that money.’”

Greater power leads to policy victories, which leads to a better environment. In Fresno, the system is changing.

Most institutions do not have patience denominated in decades. Foundations give grants for a few years; nonprofits see about a fifth of their employees turn over every year, on average.

Many of us are not going to see the outcome of this work.” She knows it will be her children—and more likely, her grandchildren—who will reap the benefits of the changes.

Because when it comes to preventing problems in complex systems, finding the right lever and fulcrum is precisely the hard part.

In 2008, in the midst of a crime wave in Chicago, the University of Chicago (UC) Crime Lab was cofounded by three colleagues: