Upstream: How to solve problems before they happen

by Dan Heath

Their goal was to build an evidence base that policymakers could rely on to reduce crime—to bridge the gap between academic research and public policy.

Through that lens, the violence seemed intentional, even strategic—the by-product of gangs jockeying for money and power.

(Upstream leaders should be wary of common sense, which can be a poor substitute for evidence.)

Here was a typical case: Two groups of teenagers were arguing in the middle of the afternoon about whether a kid from one of the groups had stolen a bike.

Another kid felt disrespected by that move and pulled out a gun and shot the kid in the back.

These cases were not gang related. There was no strategy to this violence. The deaths were needless.

“Very often you read these reports and you think, ‘I just cannot believe that someone is dead because of this,’” said Pollack, the public policy professor.

“My fundamental equation is a couple of young guys plus impulsivity, maybe plus alcohol, plus a gun, equals a dead body.”

He’d arrange the young men in a circle—there were usually 8 to 10 in each class—and ask each to reflect briefly on how he was doing that day: physically, emotionally, intellectually, and spiritually.

As one young man said to researchers who were studying BAM, “I like how we can just sit down and just talk to each other … it’s calming.”

They evolved into a fascinating hybrid, blending the confessional aspect of support groups with the tough love of male mentoring and elements of cognitive behavioral therapy (CBT), a technique that helps people learn to change their patterns of thought and, as a result, their behavior. Beyond that, it had to be fun. It had to be cool.

Balancing these demands was a tightrope act, but it seemed to work. There was never a shortage of young men who wanted to join BAM.

Among the students who participated in BAM, arrests were down 28% versus the control group.

Violent-crime arrests were cut practically in half (down 45%).

The Crime Lab researchers concluded that the BAM program had been successful in getting teenage males to slow down their thinking in fraught situations.

Immerse yourself in the problem.

She challenged those leaders to do detailed case studies of the last 50 patients who had died at each of their hospitals. To their astonishment, about a third of those deaths were due to sepsis, a problem that was barely on their radar at that time. By 2011, those leaders had reduced mortality for patients with sepsis by 60%.

If you work on a non-deadly problem, you’ll have other strategies for getting closer to the problem.

The architects Mike Steiner and Samantha Flores went a step further, though. They donned an “age simulation suit,” which is designed to make you feel what it’s like to be old.

In searching for a viable leverage point, your first pass might be to consider, as the leaders in Iceland did, the risk and protective factors for the problem you’re trying to prevent.

Every problem will have its own array of factors that increase risk for or protect against it, and each of those factors is a potential leverage point.

The pool of people who are riskiest—and most at risk—is small.

One of the most baffling and destructive ideas about preventive efforts is that they must save us money.

These aren’t irrelevant questions—but they aren’t necessary ones, either. Nothing else in health care, other than prevention, is viewed through this lens of saving money.

Let’s not sabotage upstream efforts by subjecting them to a test we never impose on downstream interventions.

That’s the kind of perspective that is spreading quickly—a growing appreciation for the importance of the upstream factors that influence health.

On the other hand, there is an understandable reluctance to “own” patients’ upstream health needs, simply because so many of those factors are outside the purview of the health system.

One new medical school, the Hackensack Meridian School of Medicine at Seton Hall University in New Jersey, is pursuing that vision, reinventing the way doctors are trained.30 The social determinants of health are at the core of the curriculum.

Aamirah McCutchen and a classmate, both first-year students in the first-ever class for the med school, were matched with a 91-year-old man in a nursing home.

The students asked him what goals they could help him with. He said, “I’m ninety-one. I don’t really have a goal.”

But then he came up with two things: learning to use a computer and fighting his short-term memory loss.

Another pair of students were matched with a man who had uncontrolled diabetes.

He’s dependent on a neighbor for his food. So it was harder for him to ask for the specific foods (often perishables) that would have helped him manage his condition.

Another part of the medical students’ work is to engage with the community, not just particular people.

At first, the students were enthusiastic about this work. Maybe overenthusiastic. In the first few weeks of school, they’d show up at Rocchetti’s office with plans for solving various community problems. Then, in the middle of the year, the reality of exams and board preparation started to intrude on their idealism.

Learning to appreciate the full complexity of people’s lives as well as the complexity of the systems in which they operate.

Nothing is easy. The world is complex and there are no quick fixes. But if I can learn to uncross my arms and extend my hands, I can be someone who eases suffering rather than ignores it.

“Our students are going to grow up and be the force that changes the culture.”

Bryan Stevenson, a law professor at NYU, author, and the founder of the Equal Justice Initiative, calls this the “power of proximity.”

“I believe that to make a difference in creating a healthier community, a healthier society, a healthier nation, and thus a healthier economy, we’ve got to find ways to get proximate to the poor and the vulnerable,” said Stevenson in a speech to Fortune’s CEO Initiative conference in 2018.

I am persuaded that in proximity there is something we can learn about how we change the world ….”

But in this context, even a defeat is effectively a victory. Because every time we learn something, we fill in one more piece of the map as we hunt for the levers that can move the world.

Saxena found that there was a strong negative correlation between product usage and churn.

“We found that customers who engaged [with the product] in the first 30 days were four times more likely to continue using LinkedIn,” said Saxena.

“We said, ‘Let’s take all these resources that we’ve been using to “save” customers and apply them to onboarding clients properly.’”

These onboarding specialists would actually do some of the clients’ work for them.

Within two years, the churn rate was cut roughly in half, even as the company’s revenue exploded, and one of the critical drivers of that success was the onboarding work.

At LinkedIn, the smoke that activated the alarm was a customer’s inactivity in her first month as a subscriber.

There’s no inherent advantage to early warning signals. Their value hinges on the severity of the problem.

The value also depends on whether the warning provides sufficient time to respond.